Feds Use Data Analytics to Detect Fraud

A Jacksonville-based healthcare provider accused of making false or fraudulent claims with the Florida Medicaid program agreed to pay $700,000 to resolve allegations it violated the False Claims Act.

The case against Physicians Group Services resolves allegations that PGS submitted claims to Florida’s Medicaid program for quantitative urine drug testing that were medically unnecessary because the testing was not individualized to the needs of the patient.

The investigation focused on urine drug testing (UDT), which occurs in a variety of healthcare settings. In a pain management practice, UDT is used to monitor whether a patient is taking prescribed drugs, is taking non-prescribed drugs, or is taking them with prescribed drugs other dangerous substances, such as alcohol. UDT is either “qualitative†or “quantitative.â€

These quantitative drug tests identify and count particles of illicit drugs in patients’ urine. These drug tests are very specific, expensive and generally considered appropriate only if there is reason to doubt the more general and cheaper qualitative drug test screens. 

A qualitative test tells you if a particular substance (analyte) is present in the urine specimen. A quantitative test is more specific in that it tells you how much of an analyte is present.

This isn’t the first time Physicians Group Services has faced such allegations. In 2016, the company, doing business as Coastal Spine and Pain, agreed to pay $7.4 million to resolve allegations it violated the False Claims Acy by performing medically unnecessary drug screening procedures.

At that time, it was alleged that Coastal appropriately performed qualitative drug tests for its patients. However, regardless of the result of the less expensive qualitative test, Coastal also performed and billed for quantitative drug tests for all patients. The government contends this was medically unnecessary, as there was no reason to question or further confirm previous qualitative urine drug testing screens. 

We have written about similar types of cases over the years.

Providers often become the target of these investigations using data analytics. Through data mining and the use of predictive analysis, thousands, or even millions of transactions, can be searched to detect patterns of questionable billing practices.

The Health Law Offices of Anthony C. Vitale has extensive experience representing clients in audits and overpayments and we can represent your interests through all of the stages of the overpayment appeals process. In addition, if you find yourself the target of a fraud investigation, our team can assist you every step of the way. Contact us for additional information at 305-358-4500 or send us an email to info@vitalehealthlaw.com and let’s discuss how we might be able to assist you.