Practitioners end up at risk in drug testing because they lack knowledge of the policies that payors put out on medical necessity. They also can get into a lot of trouble if they don’t understand the mechanics of the clinical laboratory regarding presumptive testing and definitive testing. It’s important that the provider do due diligence before they get into any laboratory arrangement, whether it’s their own laboratory or with an independent laboratory. That’s where a lot of the cases have happened. In the last year there have been several lawsuits, criminal cases and fraud investigations, and most of it relates to lack of knowledge of medical necessity and lack of proper documentation.
There are ways to document medical necessity. The most important step that a provider can take is to understand what the state licensing board wants them to do regarding drug testing and then compare that with a carrier’s medical policy on drug testing. They can then create their own template so that they can document what’s required of them on both sides – the licensing board and the payor, and tell them why this testing is being done for this patient and most importantly, how the test results are going to be used, and what we are doing for the patient as a result of the test.
Primary care needs to understand that there are requirements for drug testing and that the frequency is not tied to their subjective perspective of whether the patient is at risk or not. It’s the fact that the patient is using an opioid; and that if they’re using the opioid chronically, that drug testing should be part of their risk management protocol. Practitioners should endeavor to look at their licensing board materials and medical policies to understand when they should order these tests and what should be documented.