If patients are prescribed opioids, ‘best practices’ calls for
– assessment of risk for dependency and addiction;
– completion of an Opioid Agreement:
– ongoing assessment of pain and functionality; and
– random urine drug testing (UDT).
This last has become – for some – yet another of the myriad ways to suck money out of the workers compensation system. Yet there’s no question UDT is a necessary component of opioid management.
Today’s WorkCompCentral arrived with an excellent piece on the issue authored by Greg Jones. The premise of the article is a flap involving accusations of overbilling by a former employee of a company that allegedly does billing for drug tests.
The details of the controversy aren’t what’s important.
What’s important is for payers to understand two things:
a) drug testing is a critical piece of opioid therapy; and
b) just like physician dispensing, MRIs. PT, surgery, heck almost anything, it can be gamed, over prescribed, abused, and made into the proverbial money tree.
Properly done, drug testing enables physicians to determine if the patient is taking the prescribed drug; if they’re taking other drugs that may be contra-indicated; and/or if the patient is taking illicit drugs. Given the issues with addiction, abuse, diversion, and misuse, drug testing is a critical component of the medical management process.
Grossly over-simplifying the issue, it boils down to this. Fee schedules and reimbursement rules allow physicians and labs to bill multiple codes for multiple ‘tests’ for different drugs – so, the more tests, the more money. Typically, physicians bill for testing that just indicates the likely presence or absence of certain drugs, and a lab bills for ‘confirmation’ using much more sophisticated processes and technology.
There’s a reasonable argument to be made that paying docs to test in their offices encourages compliance with opioid management best practices, as long as the amount paid is also ‘reasonable’. Unfortunately, the research indicates UDT is grossly underutilized; one study found fewer than one of every seven physicians treating patients with opioids test their patients.
In-office testing is also much less reliable than lab-based testing; therefore any office-based test result must be confirmed with a test at an accredited lab.
So, the conundrum is this: payers want to encourage drug testing, but don’t want to get stuck with outrageous bills. There are several tactics payers can use.
1. Inform contracted physicians that drug testing in office will be reimbursed at $XX.XX – a flat rate regardless of the number of drugs tested for.
2. Drop physicians who refuse to comply from your network.
3. Require proof of testing and assurance that the prescribing doc has reviewed the test results and factored those results into ongoing treatment.
4. Contract with a lab for a flat fee to cover a comprehensive list of drugs; this ensures the physician has a full view into the patient’s drug consumption while capping the payer’s fees at a ‘reasonable’ rate.
What does this mean for you?
Drug testing is necessary, it’s also ripe for abuse.
(Disclosure – Millennium Labs is an HSA consulting client)
Apr
9
Hey Joe – excellent post! About two years ago, we implemented a UDS program with an independent lab. Our expectation is that treating physicians use the independent lab to drug screen any injured worker receving opiates. As you can imagine, despite treatment guidelines and the willingness to pay for the drug screen, this policy was met with mixed emotions among the physician community. With the samples submitted,over 50% had aberrant findings. I must say i was disappointed, but not surprised! With these findings of abuse, non-compliance and failed treatment, i believe we have an ethical responsibility to ensure that drug testing is not only part of the treatment plan, but that the results are documented and acted upon. This is a work in progress, one claim at a time.
I would recommend simply that regardless what vendor is utilized for this, to ensure a random quantitative urine drug screen is used, at least every six months, and more often as necessary. Most of the in-office UDS tests are qualitative, meaning they are typically dipstick type tests that result in either a positive or negative. However, this type of testing is grossly inadequate. For example, if a claimant takes a single tablet of Vicodin, hours before the UDS, and sells the other 100+ tabs, the test will not show this. If the claimant is taking the prescribed Vicodin, as well as morphine and other opiates, the test will not show this. There are many more reasons to differentiate the two, needless to say, demand that the test be quantitative, meaning you are provided with a numerical value indicating an approximate range of medication metabolized by the claimant, as well as a much more definitive breakdown of what the claimant is actually taking and not taking, and not simply a typical five panel yes or no type test. Of course, you are still left with the major problem of once the test shows an inconsistency, what next? That is another discussion all together. Seek out the help of a vendor that specializes in pharmacy review, they can help you decipher these issues, among many more, ensuring safety for the claimant and costs control for the claim.
Great comments but the reliabilitly with quantitative testing in my experience is a sloppery slop if you expect to know how much or how copliant the patient/claimant has been. I have not seen a study or studies where a toxicologist speaks to matching levels wtih amount of drugs consumed. too many factors such as weight, kidney function other medication interactions. When I practiced I used qualitative very effectively