Northeast Florida pain-management clinic reaches $7.4 million settlement over unnecessary testing of elderly

Aug. 31--A Northeast Florida surgery and pain-management clinic will pay $7.4 million in fines to the federal government in a case of excessive billing over a pattern of drug testing that included expensive screening of elderly patients for drugs such as ecstasy, cocaine and heroin.

Coastal Spine and Pain Center, which operates clinics in Jacksonville and across the region and sees an estimated 200,000 clients a year, reached an agreement that said it performed unnecessary drug screenings of patients then charged Medicare and Tricare, the medical insurance provider for military veterans. The settlement covered only government billings.

The fine represents a doubling of the amount the company billed for tests conducted from August 2015 to Feb. 1.

"The United States Attorney's Office is committed to taking the steps necessary to protect Medicare, Tricare and other federal health-care programs from fraud," said U.S. Attorney A. Lee Bentley III. "When health-care practitioners conduct medical tests, they must only bill for them when it is appropriate and medically necessary. We will vigorously pursue providers that perform tests indiscriminately, regardless of need."

In each case, the company charged thousands of dollars for a series of two tests, even when there was no justification for the second more expensive screen, said Jason Mehta, an assistant U.S. attorney in Jacksonville.

The settlement with Coastal, which, according to its website has locations in Duval, Clay and Nassau counties as well as Southeast Georgia, is a settlement of allegations and does not assign liability, according to the agreement.

Coastal's parent company, Physicians Group Services P.A., based in Middleburg, said the company's management "decided to settle the matter to avoid expensive and protracted litigation and to allow us to focus on our patients," according to a statement from attorney Elizabeth Shaw.

The company was ready to defend the appropriateness and medical necessity of the quantitative testing, the statement said.

The U.S. Attorney's Office said Coastal was unnecessarily doing the double screens for a wide range of drugs on each patient the physicians saw. A handful of pain-management physicians at Coastal who ordered the tests will make the payments, Mehta said.

The company knew or should have known the tests were "not medically reasonable or necessary," according to the settlement.

As an example, the practice included testing 80-year-olds for exotic and illegal drugs, first with a test to detect the presence of those and other more common drugs and then, even when no evidence was found, with a much costlier screen that would detect the exact quantities of those drugs in the person's system.

The action constituted abusive billing, Mehta said.

Two sets of tests were done by analyzing urine samples.

The initial set of tests, which would detect the presence of drugs is not in dispute, Mehta said. Those are qualitative tests and show if the sample contains any of about a dozen categories of drugs and could include separate tests within each category.

That is a reasonable action for a pain-management clinic and widely warranted. The tests cost hundreds of dollars, Mehta said.

"What Coastal did is regardless of what these results were in that cup, they took the urine and they put it into this very sophisticated machine that they bought and did what they called confirmatory testing," he said. "They confirmed that the results they had in their point of care cup were accurate. And that is thousands of dollars, not hundreds of dollars."

Unlike other clinics that use the same testing standards, but perform them in a much smaller percentage of cases, every client of Coastal was tested, regardless of the initial test results or other factors that might rule out the likelihood of drug abuse.

Every patient was tested every time for every drug, Mehta said.

"Even if the results were negative, they ran this very sophisticated, very expensive test to confirm that the tests were negative," Mehta said.

New guidelines governing protocols for how such tests are conducted were implemented in mid-August of 2015 after Medicare noticed widespread billing for double tests.

"They started seeing, all across the country, individuals, elderly, above the age of 65, are getting tested in extreme quantities," Mehta said. "And it just doesn't make sense."

Among clinics in the Department of Justice's Middle District of Florida, which stretches to Tampa, Coastal stood out when the U.S. Attorney's Office scrutinized billing patterns following the new regulations.

For each bill the company submitted for the initial, less expensive tests, an accompanying charge was submitted for the second screen.

"You should really only be doing the quantitative testing if there is some blip on the radar, some probable cause and there is just nothing here in any of these patients to suggest that," Mehta said.

The new regulations addressed the issue, he said.

"They said, 'You can only do this quantitative type testing only if there is probable cause, a reason to do it,'" he said.

The investigation of Coastal covers only the six or seven months following the rule change. Federal prosecutors used a sample of about 60 cases, though the settlement covers all of the tests that were done during that period.

Coastal, Mehta said, was cooperative when it was questioned about the issue and that the settlement was agreed to quickly.

"I don't think they are intentional bad actors," he said. "They were very cooperative, and they realized this was not justifiable, this is not legal."

Dana Treen: (904) 359-4091

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