Stark Realities of Urine Drug Test Orders and Payment

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Here’s a new one – I have some newfound Rachmanus for the payers…that’s an Italian word (wink wink) for compassion. But as they also say in Italian, con amore ma non troppo (with love but not too much).  In other words, I have some compassion but not too much empathy.

The payers are bleeding, or maybe “peeing”. What causes bleeding in the insurance industry? Hemorrhaging is caused by unanticipated innovations in the way of drugs, devices, or tests, but more particularly unanticipated utilization and submission for payment. And right now, unanticipated utilization of urine drug testing is causing a hemorrhage. It is through the roof. So much so, that there are several policies on the table that could jeopardize the availability to state of the art lab tests for those of us who treat pain and addiction and use laboratory testing only as medically necessary. Trying to stop the bleeding  with a tourniquet that might sacrifice their arm, some of the Blues have been threatening to turn the clock back 50 years and revert to out of date technologies and take the kind of information that pain and addiction clinicians need out of their hands. Reverting to a strictly immunoassay (IA) based policy and denying confirmatory testing either entirely or of IA negative specimens, the re-instituting of this forensic testing method and mindset is a desperate effort on their parts to curb skyrocketing lab costs.  And of course, this is from the very same folks that often deny abuse deterrent formulations, other branded extended release formulations, limit of physical therapy, deny procedures such as acupuncture, limit chiropractors or alternative therapies, behavior health, diet/exercise, and healthy lifestyles – yet, third party payers seem to slither away unscathed without blame for the presumed “opioid epidemic”.

It is tempting to think that the big “confirmation” labs are behind these increases. Certainly their utilization has increased in this era of expanded legitimate opioid prescribing, misuse, abuse and overdose, in an altruistic attempt by clinicians to render opioid treatment safer for pain patients or to offer recovery support to the huge influx of newly recovering addicts in treatment centers.

If this were all it was, my compassion for the insurance industry paying for these lab tests would be zero!

But good patient care is not the only reason that labs are ubiquitously ordered. And the reason that I don’t have full compassion for the payers is because they are using their policies as a blunt instrument to curb bleeding without fully understanding the bloodletting source.  And as is often the case in these scenarios, it is this blunt instrument that can have many unintended consequences, one of which is indiscriminately taking down the good doctors (and patients) with the bad.  Undeniably, the payers’ “spend” of billing from this illegitimate source is orders of magnitude higher than the frequency of necessary testing.

Without a doubt, I believe that most pain clinicians who choose to treat with medication management as part of an overall armamentarium certainly have their heart in the right place.  They care for medically complex patients that are frequently outcast by other providers.  They carry a high liability, much anxiety, deal with political issues, the DEA and state regulatory agencies, and are often living in a nerve wracking nightmare for providing compassionate care.  Indeed, they could come under scrutiny for ordering such tests without adequate documentation for need or for lack of follow-up and actionable outcomes based on the lab test results.

Nevertheless, while we have all heard about fraud and abuses in the industry, perhaps it also exists, in some cases, on the provider end. There are providers in some instances who used to test urine infrequently but now test patients over and over again with large and expensive panels, as this has become a huge revenue source. These entrepreneurs are not doing anything illegal; in fact they are driving through a loophole in Stark Laws so big you could drive a Mack truck full of urine through it. Some greedy labs are threatening the availability of a tool that many of clinicians rely on in our clinics.  But interestingly no one seems to regulate or write about this aspect of unethical practice (interesting in a time when regulating pain practice is at a Zenith) and I find this transgressive and embarrassing for the professions. You’d think payers would lobby for a law and media muckrakers would be all over this…but when you are talking about the sacred cow of revenue, you are talking about one of the last few topics that make payers, reporters and congressman quake in their boots. And the poor patients, afraid of losing access to their medications, who need urine drug testing to help them objectively demonstrate their adherence in an era when they are constantly stigmatized, are often frightened to question [over-the-top] testing themselves even if they recognize it as excessive. At a time when fewer and fewer patients can rely on finding prescribers willing to treat them with the opioids they need, if they get the message they can only have their medications with frequent testing, they will do it – they are over a barrel. 

So many politicians railing about prescription drug abuse and wanting to do something about it and no one wants to be the next Pete Stark? You see it seems there are a lot of chicken mavericks out there who claim to be fraud busters and the like; but to understand why they don’t step up is to need to know something about Pete Stark, the father of the laws that forbid physician self-referral who just left his congressional district in California after serving 40 years. (who by the way was recently quoted as saying that with all the exceptions rendering his law ineffective he himself wouldn’t now vote for his own law!).

Stark clearly was pretty much immune to fears about being re-elected for much of his time serving, but it doesn’t end there. While he had to apologize on many occasions for ill-advised and offensive comments over the years, Stark was his own man. The first openly atheist member of Congress he was vocal about taking unpopular positions. He was for national healthcare reform….in 1990. He voted against the Iraq war. He was against the government buy out after the crash. Whether you agree with these positions or not, he was his own man, an iconoclast and someone not afraid of taking on powerful and sacred cows.

Stark, as many others, knew that physician ownership and fractional ownership of imaging centers and labs and other forms of self-referral were bad for healthcare and bad for healthcare costs. Studies have shown for example, that when doctors have a financial interest in imaging centers they order a lot more imaging…and particularly a lot more negative imaging. See for example, Doc financial interest may influence MRI referrals or Inquiry Challenges Doctors On Ordering Diagnostic Tests. Exceptions were made for labs to provide instant and point of care information and facilitate providers to work together and share cases in large institutions. But doctors running analyzers on a day’s or week’s specimens at 11pm or on Friday afternoon hardly qualifies, nor does billing for point of care IA, analyzer IA and chromatography all in office with 3 separate charges being generated. 

This is the stark reality. And we need a solution other than a blunt, ill advised, regressive set of payer policies that will render pain and addiction treatment far less safe for people with these already stigmatized problems.

As usual, chime right in folks!

8 thoughts on “Stark Realities of Urine Drug Test Orders and Payment

  1. I’m have found myself in the most ridiculous position that I have had the misfortune to face. You see, I am a chronic pain patient and have been for 17 years now. Recently, with the changes in federal law relating to prescribing opioids for pain I am finding that if indeed I can find a doctor to prescribe the medication I need to live a life as close to a normal life as possible the price I pay monetarily coupled with the price I pay psychologically are tremendous.
    Let me first tell you about myself. I am a 50 year old female living in the state of Texas. In 1999 I began having debilitating lower back pain to the point that I was forced to leave my profession because honestly, some days I just could not move without tremendous pain. I was diagnosed with Degenerative Disc Disease and subsequently had my fist lumbar back surgery in 2000. When my pain level increased instead of decreasing it was followed up by another lumbar surgery in 2002. Approximatly 1 1/2 years after the surgery I entered rehab to be weened off of the pain medication. I tried to live as normally as I possibly could which to be honest was a life not worth living and in 2004 I went in for back surgery number three. This time instead of taking bone from my hip, titanium rods and screws formed a cage around my lumbar spine from L-2-3, 3-4, 4-5 and 5S1. After a year of recouping from this latest surgery and physical therapy that seemed to cause even more pain I one again entered rehab to detox from these pain medications. Once again it didn’t last long. The pain was so overwhelming that I honestly on more than one occasion thought that death would be the best solution.
    I am not proud that this thought entered my mind just honest. So, once again I was back on Norco 10/325. As my pain level continued to increase I found myself back in the office of a the back surgeon for back surgery number four in 2008. This surgery was much more invasive as it was a 360 and two discs were replaced and my “bent” titanium was removed and replaced with double the amount. At this point my back surgeon stated that he would not even consider doing another surgery for fear that my body might not be able to “take it”. I was then placed on OxyContin immediately after leaving the hospital and two months later I requested to be brought back down to Norco. Honestly, the stronger medication scared me and my thinking was I had done years of research on Norco and the and how it affected the body yet little research on OxyContin. And it honestly in most cases took enough pain away where I could function at about half of my normal capacity.
    Since 2008 my back pain has unfortunately gotten worse instead of better and I was told by one doctor that I would most likely have to remain on pain medication the rest of my life.
    Those eight years were the absolute lowest years of my life. I had been so active before the initial pain started in 1999 working out at the gym Monday thru Thirsday a minimum of two hours a day that included high impact aerobics, and Friday thru Sunday I would run a minimum of 2 to 3 miles per day. In between I worked a full time job, sometimes I would even add a part time job into my schedule and was an avid racquetball player, water skier and numerous other physical activities. I loved being active and healthy.
    So, you can imagine the hit my happiness and self esteem took once my pain started in 1999 and the following years included depression that I never even knew I was able to feel.

    Please understand these are only the highlights. I’ve had numerous testing and injections some more painful than others.
    To this day I am still on the same amount of pain medication and the only time it was changed was to find out if something else would be a better fit. However, after some pretty scary side effects of various pain medications I agreed to try I returned to the Norco and have been there ever since.

    This brings my to present day. While I completely understand why it was necessary for the rules regulating opioid pain medications, I have also found that just because a doctor specializes in pain management it doesn’t mean that they are willing to prescribe opioids. Before, the regulations changed and after seeing pain management specialists my primary care physician had taken over my treatment since it was Norco and a muscle relaxer he felt comfortable doing so as did I . Of course, if anything arose like a very bad car accident which two happened I would once again go to the pain specialist because the pain was much worse and did for a time require something a bit stronger. However, once I felt that something stronger was no longer needed, never more that about two months, I would return to my PCP and once again he would take over.

    Everything changed about four months ago when my PCP told me honestly that with all of the new regulations, he was requesting that myself and any other pain control patients he treated go back to pain management doctors so it would not put him in or his practice in an unfortunate situation.
    Quite understandable, I wouldn’t want to risk my practice if I were him and he is still my PCP.
    So my journey began, I needed a doctor that I felt comfortable with because yes, this is strong medication that I was on and I wanted a doctor that also had some faith in me, that I was not abusing my medication and didn’t look upon me as some kind of a “junkie” because let’s be honest there are doctors that look down on chronic pain patients. Not all mind you but, more than I ever realized. I chose a doctor based upon a recommendation from my PCP who knew none personally but, gave me a list of local pain doctors.
    I had my first visit with Lets call him Dr. X in May of 2016, signing a contract with him I agreed to a UA each and every month. This was not concerning to me after all, we were not familiar with each other and I quite frankly saw no problem with this. How naive I was. The first visit was ok although he did state on the first visit that he wanted me to think about him implanting a SCS. This concerned me because quite frankly other than my chronic pain I am quite healthy and my depression is almost nonexistent.
    Then it happened, I got the first EOB from my insurance company and the charge for the UA was $1000.00. I thought this was an awe full lot and called the billing department.. I was told that this is what they charge my insurance company. Seemed like quite a bit of money to charge my insurance every single month and while I am very lucky to have good insurance because of my husbands profession I receive no government assistance and my husband does not make that much money. There are actually some months it’s between being able to afford our medications or paying a bill that needs to be paid.
    On my next visit I decided to address this with him and express my concerns. And while he seemed understanding about the situation something else happened that day. I had an appt. with him at 1:15 and had scheduled an interview for a part time job at 4:00 because honestly I needed it to be able to afford to see this doctor. It was 3:28 when he finally walked into the room for my 1:15 visit. Needless to say I missed the job interview and a chance at a possible part time job because if I had left well, I would not have gotten another appointment in time to get my meds refilled on time. Then I noticed something else, after producing my urine sample I then had to walk around in the back of the office for someone to give it to. When I finally found someone, I noticed they just placed my sample in an area with no less than 15 other samples and in no way secure from theft of sample or worse tampering. This is what my insurance company was being charged a thousand dollars a month For? I was stunned and quite frankly infuriated of the blatant careless way my urine was treated.
    So, I thought maybe this isn’t the best doctor for me.
    I looked down my list and made an appt with a new pain management doctor that hopefully I would feel more comfortable with.
    Let’s call this Doctor Dr. Y. I went to the appt thinking you should really be able to interview a doctor to see if they are a good fit for you. And for all intents and purposes this is exactly how I approached the visit with Dr. Y. I explained to his N.P. That I was still under contract with Dr. X and could not be written any scripts by Dr. Y however, I wanted to more or less see if this would be a good Dr. to take care of my long term pain management. It was at this visit that it was discovered that I had scoliosis and a disc in the T area of my back was completely gone. Which explained the temporary off and on loss of the use of my hands. Although I had not met the doctor I liked the Nurse practitioner and told her that I would make an appointment for the following month after I wa no longer under contract with Dr. X.
    Today I received my EOB from my insurance company and per usual I look it over. I was stunned at what I saw, My insurance had been charged $9880.00 for a UA that I never took. I was at a loss for words.

    Here is my point although I know what it could cost me in the long run physically and mentally I will not stand idly by and let these doctors charge my insurance company an exorbitant amount of money for a test that was never even preformed. And while I understand this charge could have been a mistake on the part of office personnel assuming that I did provide a urine sample for testing, I called the office to explain that I did not take this test and was asked 3 times “Are you sure you did not pee in a cup?”
    I assured her that 4 surgeries has not affected my brain and I knew that I did not provide a sample I am still in absolute shock that my insurance would be charged $9880.00 for a drug screen urine test.
    At this point I am feeling the anxiety and depression creep back in and although I will do everything in my power not to allow it to invade my life, I’m at a loss as to what to do. This cannot continue, I can’t afford it, there is absolutely no way that I will be able to pay these medical bills. I read your words and they hit me like a ton of bricks, while extremely informative there must be a way to stop this. The laws regarding what a doctor can charge for a UA must have some kind of regulation. If not what will happen to those of us who need pain management yet cannot afford it??
    I am willing to stand up and tell anyone and everyone willing to listen that this can not be allowed to continue however, I’m not sure how to even begin. I am only one person out of many that I am sure this is happening to and I want to be a part of the solution so, any help or advice you could give me would be greatly appreciated. Thank you in advance for taking the time to read this and I will gladly take any suggestions you may have on the subject.

  2. This is what we are dealing with in Kentucky:
    Addiction Recovery Care: Providers the ones Abusing Suboxone treatment
    A lot of people don’t like Suboxone treatment because some patients abuse or sell it. It is accepted that addicts aren’t perfect, but when doctors and counselors abuse the actual provision of treatment it is inexcusable. It’s amazing how greed and money acts as a narcotic for supposed healthcare professionals. The biggest threat to Suboxone treatment is healthcare fraud and patient rights violations, not addicts misusing the medication.

    In April 2015 Kentucky DHS enacted regulations (907 KAR 3:005) forbidding prescribers from charging Medicaid members cash for outpatient buprenorphine treatment. Prescribers previously enjoyed a $300-400/month fee each month from the patients, and now must bill Medicaid for the office visit. There has been widespread criticism from Suboxone prescribers about Medicaid reimbursements being low, which is around $42 for a routine physician visit.

    ARC responded with a scheme to circumvent the regulation, which is force patients to undergo more counseling and drug testing to generate higher insurance reimbursements. Prior to April 2015, prescribers doing business with ARC only required 1 counseling session and drug test a month. Now it is 8. ARC requires all current/former employees and physicians they contract with to sign a non-disclosure agreement regarding their business practices. ARC has a secret kickback arrangement with prescribers who both deceive clients by using misleading or false reasons for such intensive counseling/drug tests such as “that’s the new state law” or that “insurance won’t pay for the visit” or “your insurance requires it” unless clients get counseling and drug testing exclusively at ARC, and at least twice a week no matter if they are doing well or not, with no consideration of individualized treatment planning. ARC also requires clients to sign contracts that forbids them from going to another drug counseling facility, and signing a power of attorney form that gives ARC control of their health insurance account. ARC makes deals with buprenorphine prescribers, who sign a non-disclosure and noncompete agreement with ARC. All ARC employees must sign a secrecy contract and are threatened with litigation if they tell anyone about ARC business practices. If you call them with any questions about counseling/drug test requirements or costs they will use scripted responses like “you will have to contact our corporate office” who of course do not return calls. ARC refuses to give anyone medical records. Licensed facilities are required to give individualized treatment and keep truthful documentation including progress notes and assessments. Disclosing medical records would expose them for overutilization and falsifying medical records, as they must make it look like the client is not doing well in order to justify such frequent office visits. However, since Suboxone is such a good medication, after the first month at least 90% of clients will be stable, happy, functional-working, in school, being good father/mothers, have no desire or risk for relapse, and have clean drug tests. This is not good for business at ARC, so falsifying medical records becomes a necessity.

    ARC was able to coax over 20 of my MAT clients, some I’ve had for 5 years, to stop seeing me as their counselor. There are 2 main reasons MAT clients switched to ARC. First, they get their physician monthly fee waived as ARC pays it, saving them $300-400 each month. Secondly, clients are “strong-armed” i.e. if they do not get counseling and drug tests at least twice a week, ARC will collude with the prescriber and threaten to discontinue their buprenorphine prescription. ARC does not base treatment modalities/frequency on evidence-based practice or individualized care despite it being a requirement for a state-licensed facility. Instead, ARC enforces a “standing order” policy that requires a minimum of 2 hours a week for all clients (see https://www.arccenters.com/outpatient-centers).

    Think of ARC this way: Say there was a regulation barring cardiologists and PCPs from charging patients cash for routine office visits. Doctors that prescribe statins for heart disease or metformin for diabetes now must rely on insurance reimbursements, which only pay around 10% of what they were getting from patients out of pocket. Frustrated, they force their patients to come 8+ times a month to tack on medically unnecessary counseling, educational groups, and lab tests for a cut of the insurance payout. They contract with unscrupulous businessmen who hire incompetent/venal counselors and lab techs. It is the patient’s right to choose whether or not they want to take medication for their disease, or undergo non-pharmacological alternatives e.g. lifestyle changes, or a combination. Of course most patients stabilized on either of these medications are relatively content with the medication and do not want or need 8 ancillary visits a month, but if they complain or refuse to attend they will be threatened with dismissal and getting cut off their life-saving medication. Although qualified to do so, the physicians do not provide these extra services because they know it’s a waste of time and only want the revenue they generate. This is precisely what ARC and prescribers are doing with MAT patients.

    Usual and customary fees in drug use treatment are around $100 an hour for counseling, $30 for group counseling. ARC is charging $475, $375 respectively, sometimes getting reimbursed the full amount. They use a billing agency based in Florida who use obscure hospital CPT codes. I have extensive written documentation including EOBs from Anthem and WellCare clients who use ARC, some showing over $12,000 in payouts for 1 month. Usual and customary fees a point-of-care urine drug test (immunoassay) cup are approx $25. ARC charges between $1,200-1,400. They charge inconsistent rates to different payors (charge Medicaid $100, but Anthem $1,200-1,400 for a urine drug test). ARC is a small office staffed by 2 counselors, a secretary and urine specimen collector. With no physician’s order, ARC staff direct each client every visit to submit a urine drug test, which is billed to the client’s insurance by ARC (qualitative urine drug screen) then sent to Millennium Labs for confirmatory testing, which also bills the client’s insurance, between $207 and $817, bringing the total cost per visit up to $2,692. Both ARC and Millennium Labs have a “standing order” to bill Medicaid recipients monthly, but clients with private insurance plans have all of their urine specimens sent for confirmation and are billed each time, up to 10 a month.

    KAR 9:270 mandates at least 8 drug tests a year for addiction treatment with buprenorphine, and monthly physician visits after the first 2 months assuming the patient is compliant. I have reviewed EOBs showing reimbursement on the same urine specimens for additional confirmatory testing by a lab (Millennium) on tests taken within 2 days. Many drugs remain detectable in urine up to several weeks, suggesting testing of this frequency unnecessary and of questionable clinical value. Millennium Labs also happened to settle a false billing and kickback claims and pay $256 million, reported on 10/19/2015. An excerpt from justice.gov regarding the Millennium case:

    “The United States alleged that Millennium caused physicians to order excessive numbers of urine drug tests, in part through the promotion of “custom profiles,” which, instead of being customized for individual patients, were in effect standing orders that caused physicians to order large number of tests without an individualized assessment of each patient’s needs. ; “The Department of Justice is committed to ensuring that laboratory testing, including drug testing, is ordered based on each patient’s medical needs and not for physician or laboratory profit,” said Benjamin Mizer, Principal Deputy Assistant Attorney General for the Civil Division of the Department of Justice.”

    Millennium performs lab confirmations on urine specimens monthly for Medicare/Medicaid patients, however if the patient has private insurance, they revert to their standing order practice and perform confirmations on every test, up to 10 a month. The prescribing doctor sees each patient only once or twice a month, thus cannot give orders for 8-10 urine toxicology confirmations a month.

    ARC also waives co-pays, a practice considered fraudulent in the insurance industry. ARC also refuses to post a fee-schedule or disclose their fees/list of services with costs, to anyone in writing. They give almost nothing in writing and do not use fax machines. They have only phone numbers for communication, no contact email or forms on their website to send and receive messages. If you are able to get an employee’s email address, they will block you if asked too many questions about policies or fees. ARC has no medical doctor serving or advising as a director, and the founder/CEO Tim Robinson has been convicted of voter fraud.

    DMS as well as private insurance companies expect licensed MAT providers to use evidence-based practices consistent with ASAM, SAMHSA, and NIDA. None of these entities, in fact no professional medical or counseling board/society recommends forced/unwanted/medically unnecessary counseling sessions past once a month for buprenorphine-assisted treatment of opioid dependence.

    Coerced clients come to therapy through the judicial system, employers or spouses, not from a doctor or licensed behavioral health facility. In contrast with counselors employed by ARC, the typical counselor’s skills of reflecting, probing, and supporting often fail with individuals who did not enter into therapy of their own accord—or who, once there, do not engage readily with the counselor. In traditional counseling arrangements, the client rather than the counselor tends to set the goals of therapy and to decide the treatment priorities. The counselor often concurs with the client’s views if they disagree on priorities or the client will go elsewhere. In coerced work, however, the client’s personal goals may well be to convince the counselor that their problems are not as severe as indicated by ARC staff. The traditional counselor strives to be non-judgmental and not tell clients what to do or what values to hold. These counselors endeavor to side with their clients and see the world from their point of view. In the coercive setting of the ARC outpatient program, however, they assume much responsibility for clients’ goals, and also make an implicit statement about arbitrary values and goals e.g. wanting them to gain employment or wean/stop medication-assisted treatment for substance dependence. ARC counselors use these values as ammunition in utilization reviews, to document that the client has failed to achieve arbitrary goals and thus justify continued or increased service utilization.

    ASAM considers weekly or monthly counseling sessions as adequate. I have been approached by several former clients who lament the fact that they have to go to ARC so often. All of them have the same negative response to the efficacy and necessity of their demand for 8-10 sessions a month. Patients with Medicare, commercial insurance or no insurance are told by ARC staff they can “buy their way out” of services at ARC by paying the prescriber $300 a month and continue to see any counselor just once a month, or more frequently should they choose to receive more sessions. This fact extinguishes any credibility to ARC’s steadfast insistence that clients come at least twice a week. It contradicts their unusually high number of required counseling sessions as somehow crucial, medically necessary, or even slightly advantageous to their recovery. Licensed BHSO/AODE facilities are required to use Interqual to evaluate client criteria on an individual basis to determine appropriate services. ARC flouts this requirement by automatically mandating every client to 2+ counseling sessions and drug tests each and every week, and exaggerating symptoms/problems in medical records and utilization reviews. Professional counselors usually see clients for 20, 40, or 60-minute sessions depending on clinical necessity which varies each visit. ARC requires the maximum, 60-minute sessions each and every time.

    For ARC, utilization of services is based on financial gain, not medical necessity. The first question staff will ask a prospective client is “what type of insurance do you have”. If you complain about the requirement for such frequent counseling sessions, often staff will admit that so much counseling/drug testing isn’t really necessary, but is needed to fund ARC and pay off your doctor. ARC does not accept any clients for counseling unless they are ordered by a buprenorphine prescriber to do so. Clients interested in getting counseling for abstinence-based treatment or MAT and willing to pay customary fees out of pocket are turned away. The reason these clients are kept out is if they joined a group of mandated buprenorphine clients they will quickly realize the shallow and minimally-therapeutic nature of the content; the groups amount to a waiting game of mostly small-talk. A client seeking help on a voluntary basis and using their own money has much higher expectations than clients coerced to attend with no out-of-pocket cost and an indirect $300/month reward. ARC cannot accept self-pay clients for 2 other reasons: Most clients would not be willing to pay what ARC charges insurance companies ($1,575-1,875 per visit for private plans, $475-575 Medicaid), and because doing so would force them to set and disclose fees, putting them at risk of getting caught for violating fee for service laws by charging different amounts based on insurance type or lack thereof.

    ARC thrives by exploiting mandated clients instead of earning business through quality service provision. ARC treatment philosophy is based on coercion and maximum insurance payouts, not best practices, thus the reason for opposing treatment models between their residential (abstinence-based, pious, against MAT) and outpatient (MAT) facilities. The referral sources for each program demand the client get treatment (judicial system ordering many to residential, buprenorphine prescribers ordering profuse outpatient services).

    Prescriber kickbacks from ARC based on how many drug tests and counseling sessions were completed. Kickback arrangements of this type (fee-splitting KRS 311.595) are legal in some cases if the patient is made aware of the financial arrangement, and if the fee is in proportion to the service performed. ARC attempts to circumvent the law by giving the prescriber a puppet consultation role or documenting kickbacks as reimbursement for rent. Nonetheless, the prescriber rarely sets foot in the ARC office and does no meaningful work for ARC. They merely refer buprenorphine patients to them and get paid for it.

    ARC staff consistently lie to patients about the insurance laws and regulations, and conspire with prescribers to overcharge insurance policies and order unnecessary drug testing/counseling. ARC staff recruit clients with practices like offering to meet them at stores or gas stations to make it more convenient to get urine specimens. In other words, ARC and dishonest prescribers work backwards from the desire to get and split up the $12,000 insurance payouts per client, per month, and do or say whatever is necessary to justify or rationalize it.

    Aside from the harm caused to clients, I fear this kind of conduct could lead to a rollback of progress and recognition gained from years of hard-fought advocacy in the counseling profession. Similarly, it could cause MAT, the best available treatment for opioid dependence, to lose public support as well as coverage by health insurers. MAT already has a bad reputation from patients abusing the medication, now we have supposed healthcare professionals abusing the provision of MAT.

    Exhibit A: Explanation of Benefits (EOB) from a Medicaid member. ARC charges Medicaid plans $375 for a group meeting, $475 for individual “counseling”, and $100 for a urine drug test cup. If your “counselor” isn’t licensed or credentialed, ARC will use what that is to bill your insurance. http://postimg.org/image/my37yv2pd/

    Exhibit B: Explanation of Benefits from a member with an Anthem commercial plan. ARC charges private insurance $375 for a group meeting, $475 for individual “counseling”, and $1,400 for a urine drug test cup. http://postimg.org/image/pv28gghdd/

    Exhibit C: Form used to tally up kickback payment. Based on number of services ordered and how many patients showed up. http://postimg.org/image/4v11r8h2p/ Here is the secret form to pay off the doctor http://postimg.org/image/e0heoimi9/

    Exhibit D: Form used to track patient enrollment, counseling attendance, and number of urine tests collected, http://postimg.org/image/hbdfj8msx/

    Exhibit E: Meeting agenda: ARC plan to strike deals with shady doctors. Note the “Non-Disclosure Agreement” (keep our business plan secret or we will sue you)http://postimg.org/image/5xkx86835/

    http://postimg.org/image/dzgyvfqsx/

    Exhibit F: ARC scheme to circumvent Medicaid regulations: http://postimg.org/image/mgx3uwi9d/

    http://postimg.org/image/ib7ykdze9/ http://postimg.org/image/5mtbyz5o1/ http://postimg.org/image/4xzt870q9/ http://postimg.org/image/o47g7chgx/

    Exhibit G: No individualized treatment. All patients get same amount (MAXIMUM) of

    drug tests and counseling sessions no matter what. NO EXCEPTIONS ($$$).

    http://postimg.org/image/qxkyqww35/

  3. Dr Fudin has, once again, so adroitly articulated some details around an enormously consequential problem that deserves much more attention than it typically gets. It’s a problem that affects not only the millions of patients and their families who needlessly suffer from untreated chronic pain and addiction, but for nearly all members of our society who carry the burden of the multitude of downstream effects on economics and quality of life. I don’t believe that insurance companies knowingly intend to kill countless thousands through the one-two punch of policies that exacerbate addictions while simultaneously refusing to adequately treat addiction. Most industries are inherently myopic in their business models, i.e., “a penny wise but a pound foolish.” No one should be surprised that this is anything other than a predictable consequence of unregulated free-market forces. The key ingredient that is turning this problem into a devastating social cancer is that many of the industries themselves are now writing the deregulating legislation that leads to the metastacies. I want to share two emblematic and illustrative anecdotes. The first is that my mother is a chronic pain patient who is now needlessly suffering more than she has in the decades since she was first diagnosed with a condition that is verified through imaging. For years she was prescribed hydrocodone to alleviate just enough pain that she could sleep a few more hours a night. Very mindful of the risks of chronic use, she chose a conservative approach that involved only using it at night. It didn’t solve all her problems – she’s also actively engaged in acupuncture, physical rehab, and nutrition – but as anyone in this profession should know, sleep is a keystone of health. Last year her provider told her that she was required to be drug-tested at every visit, “by law.” Of course we know this is a lie, though I certainly wish that more providers would ethically and intelligently use modern and accurate drug testing for the benefit of their patients. A problem I instantly recognized was that her provider was using IA technology to monitor my mothers adherence with Vicodin. An under-appreciated fact is that IA Opiate screens are not likely to detect the low urine concentrations of hydrocodone that my mothers legitimate pattern of use would have produced. She must have been coming up negative on those tests, but they kept doing them and not communicating the results to my mother. To Dr. Fudin’s point, my mother played along because she didn’t want to rock the boat. I don’t know if there were any Stark violations, but finally her doctor told her she could no longer have access to this medication. The only reason given was that the regulatory environment had become too frightening to the doctor. My mother started using lidocaine patches at this point with some relief. But her insurance refused to continue covering them citing off-label use. My mother now lives with untreated chronic pain. Think about how this situation might be the moment when some individuals would turn to heroin. And this point brings me to the second anecdote. I have a friend who is a suboxone provider. He has been outraged at times lately by certain insurance carriers refusing to cover the opioid-addiction treatment. On at least two occasions he tried an experiment: Working with a patient who had just been turned away from a pharmacy after the insurance company refused to pay for the legitimate suboxone prescription, he had the patient return later the same day to the same pharmacy but this time with a prescription for a large quantity of OxyContin. In both cases the same patient who had just been refused addiction treatment was suddenly walking out of the same pharmacy with a large quantity of the very medication that could easily exacerbate an opioid addiction. Same insurance company of course.

  4. It was only a matter of time. Urine drug tests are just one example of pain, politics, and corporate greed. Beware of the dragon, these three should not be uttered in the same sentence. It should be the person living with pain, the physician treating them, and education for all involved.

  5. My last reply was about how my Pain Specialist up and left his practice after many years of serving Cancer and Chronic pain sufferers of The Houston Pain Associates, it was sad to see him leave. But I don’t too much blame him as the pill police went after a pharmacist here in U – town 2 years after selling his privately owned pharmacy , he retired at 76 years old . I knew this pharmacist for years and now he will spend the rest of his life tucked away in a cell because he filled scripts for a doctor that didn’t have the correct license to prescribe such meds in this state 4 years ago.
    Did this pharmacist know these scripts where not legit , well someone has to pay ,its the lure of easy money that has a very strong appeal , sorry it had to be him , its the nature of the business , someone has to lose or pay .

    I thought long and hard and decided the only way to beat this thing , not being able to get my one small script for legit chronic pain of 23 years prescribed or filled, plus urinalyses test being ran on me at most every appointment is just be done with the entire thing and titrate off. Then everyone loses, NO more PAIN PATIENT , no more UI’s , no more copay to the doctor, no more copay to the pharmacy if the patient decides enough is enough and I’ve had enough , I’m done , then everyone loses , accept me .

    Seems all these years of suffering in chronic pain wasn’t all a waste , I advocated for many chronic , cancer pain sufferers , I learned a lot , and somehow during all this commotion I learned to live with the ongoing intractable pain itself, I’m off of it and its not half bad, yes I had a few bad weeks but its over.
    I just have to keep myself busy all the time and put that pain in the back of my brain.

    I had a friend call me this past weekend I use to advocate with and he cant find a doctor to prescribe to Cancer patients suffering their last days on earth there where he lives in California, that’s pretty sick , I feel bad for those people but my hands are tied.

    So thanks Dr. Fudin for all you’ve done, you’re a super nice guy and I look up to you as a very intelligent Pain Specialist and fine man indeed.
    But its time for me to move on down to the road a bit , things have become way too , well I don’t know the word to use, upside down , twisted, sick , too many chicken mavericks than cant step up to the plate like Pete Stark .

    Bye , bye all , Love U all ,

    Mark S. Barletta

  6. As usual, Jeff, you’re spot on. As you’re well aware, for the past decade, I’ve been ranting (in articles and lectures) regarding the beyond egregious practices of the insurance industry in regard to their failure to honor their fiduciary obligations to their enrollees by choosing not to cover evidence-based treatments such as interdisciplinary pain management programs, as well as essentially “murdering” patients on opioids by refusing to cover the newer (and thus more expensive) tamper-resistant and abuse-deterrent formulations. And now, UDT….. However, a number of the national labs and many physicians have been fraudulent in their UDT platforms. Unfortunately, the health insurance industry is choosing to punish a handful of “bad players” by instituting sweeping policies of non-payment for UDT. Ultimately, society will recognize that the insurance industry is committing genocide in the name of cost-containment and profitability.

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