Replies

I used to work medical provider fraud investigations for a major commercial carrier, so these were typically worker's comp claims, but also some general liability claims.

In a major injury where treatments may range over months or years, lawyers, physicians and their cronies (labs, transportation companies, etc.) would see a legitimate claimant as a cash cow to be milked to the last drop.

It is not uncommon for a long term patient to be referred to a pain management specialist who will carefully monitor their usage of prescription meds to make sure they are

1. actually taking them (and not reselling them on the street),

2. Not taking them in excess, over prescribed dosages and,

3. Not combining them with other medications or illicit drugs that could be dangerous.

All of that is legit, but monitoring these things typically depends on submission of urine/blood samples to labs for testing and analysis, and here is the basis of the scam. In some cases the doctors receive a kickback for referring the work (i.e. "billing opportunity") to the lab, and in other cases the labs will try to put one over on the referring physician and the insurance carrier. An all too common scheme lay in separate billing codes for qualitative and quantitative testing.

For example, if I was a pain management specialist and my patient had a history of cocaine and marijuana use, I would have an absolute interest in knowing if my patient was using these drugs of choice while in my care, and if so, how much they were using. The qualitative test is a binary positive/negative test for the presence of a substance. The quantitative test shows how much is present.

We found some labs, as a matter of practice would run (or at least bill for) having run quantitative tests for which the patient had already shown negative in the qualitative tests.

Quite literally, it was, "Your tests for the presence of THC came back negative so now we're going to test you again to measure the amount of THC in your system."