4 Tips to Reduce Fraud, Waste and Abuse in Laboratory Tests – Urine Drug Screening

In a 2013 report, the Institute of Medicine stated that "unnecessary services" added $210 billion to health care spending in the United States. Reducing some of these unnecessary services could help to decrease medical spending and medical costs.

We've found that urine drug screenings are one area in which evidence supports discretionary use beyond typical benchmarks. While this is one way you can monitor patients taking opioid prescriptions, ordering the more expensive tests are sometimes unnecessary. Here are four tips to consider before administering a urine drug screening and decrease unnecessary services.

  1. Evaluate medical necessity before ordering an expensive broad lab panel
  2. Medical necessity for procedures or tests must be individualized and documented in the member's medical record and included in the treatment plan of care. Patient drug testing should be tailored to the individual and include those drugs that are prescribed as well as common drugs of abuse. Orders for "custom profiles," "standing orders" or to "conduct additional testing as needed" would not support medical necessity as members care should be individualized.

  3. Document clinical rationale in medical records
  4. When you test for drug/drug classes you must document the clinical rationale for the testing in the medical record. The documentation should address how the test results will impact clinical care. Review the Priority Health Drug Testing Policy for more information.

  5. Consider where you are sending the lab specimen to be tested
  6. Contract provisions require you refer our members to network providers unless there is no one else in the network that can provide that service. Laboratories outside of the Priority Health network will subject the patient to a higher member liability.

  7. Be aware of marketing scams
  8. Many non-participating lab companies offer practices assistance in managing their chronic opioid patients with services like reports, custom lab panels, etc.  Their objective is to increase the number of tests ran on each patient as oppose to assisting the practice provide individualized care.  

You have an obligation to ensure the highest possible quality treatment for all patients, which includes the appropriate use of clinical drug testing. Appropriate treatment practices not only improve patient care they can also help reduce waste and fraud.

We know you share our commitment to combating fraud and abuse and look forward to our continued collaboration.

To learn more about how to report fraud concerns visit the Priority Health Fraud, Waste and Abuse (FWA) program page.