A brief overview on ways to strengthen your practice.
Updated: June 14th, 2024 8:30 AM
Published: June 20th, 2024 8:30 AM
Presentation Synopsis
Navigating Medical Necessity presentation by Southwest Labs provides a comprehensive overview of the evolving landscape of toxicology and drug testing from before 2012 to the present. It highlights the significant regulatory changes and increased oversight that have shaped current practices, particularly in response to the opioid crisis and the COVID-19 pandemic’s impact on substance use. The presentation underscores the importance of adhering to OIG guidelines, accurate documentation, and risk stratification to ensure compliance and avoid legal repercussions. Through case studies and practical tips, it emphasizes the need for qualitative testing before quantitative testing, patient-specific documentation, and tailored testing strategies to meet medical necessity criteria. The presentation also introduces the executive leadership team and offers contact information for further assistance.
Slide 1: Introduction
•Title: Navigating Medical Necessity
•Overview: Ways to strengthen your practice.
Slide 2: Before 2012 – The “Whatever” Era
•Summary of toxicology history.
•Context: Opioids marketed as non-addictive, drug testing primarily forensic, and the introduction of the “5th Vital Sign.”
Slide 3: 2012-2015 – Age of Regulation
•Key developments:
•Pain contracts and opioid prescription guidelines.
•CLIA audits, shutdown of bad actors.
•Increased regulations and oversight.
•Introduction of PMP review, documentation, and risk stratification.
Slide 4: 2020 – Pandemic Impact
•Highlights:
•Rise in Fentanyl-related deaths.
•93,000 drug overdose deaths in 2020.
•CDC report on mental health struggles.
•Surge in alcohol sales during the lockdown.
Slide 5: 2023 – Today
•OIG guidelines for drug testing.
•Projected $216 million savings over 5 years.
•Emphasis on partnering with labs that stay updated with regulations.
Slide 6: Current Landscape – Effects on Providers
•Changes affecting providers:
•Increased denials, patient and doctor frustrations.
•EKRA (Eliminating Kickbacks in Recovery Act).
•Risk stratification, PMP utilization, ongoing documentation.
Slide 7: Criminal Consequences of Noncompliance
•Case study: $41 million settlement by Logan Laboratories and Tampa Pain Relief Centers for unnecessary urine drug testing.
Slide 8: “Insurance Policies”
•Established policies and procedures.
•Documentation of staff training and case notes.
•Drug testing aligned with clinical encounters to ensure medical necessity.
Slide 9: Southwest Lab Review of Ordering Patterns
•Analysis of drug class orders:
•Majority (93%) of orders were for 22+ drug classes.
•Less than 1% for 1-7 drug classes.
•Emphasis on documentation matching drug class orders.
Slide 10: Qualitative Before Quantitative Testing
•Criteria for quantitative testing:
•Positive qualitative results for non-prescribed drugs.
•Negative qualitative results for prescribed drugs.
•Positive qualitative results for illicit drugs.
•Absence of commercially available qualitative tests.
Slide 11: Qualitative Testing Explained
•Types: POC cups, chemistry analyzers, semiquantitative screens.
•Importance: Document qualitative results before quantitative testing.
•Limitations and benefits of different testing methods.
Slide 12: Patient Documentation Requirements
•Necessity for patient-specific documentation.
•Orders must be specific to patient and encounter.
•Qualitative results should precede quantitative testing.
Slide 13: Frequency of Testing
•Factors influencing testing frequency:
•Test detection capabilities and patient factors.
•Treatment phase: stabilization vs. maintenance.
•Ensure testing aligns with individual patient encounters and risk stratification.
Slide 14: Key Takeaways
•Emphasis on documentation and tailored testing.
•Awareness of new insurance guidelines and compliance with existing laws.
Slide 15: Case 1 – 72-year-old Female
•Patient summary: Degenerative rheumatoid arthritis, osteoporosis, opioid prescriptions.
•Considerations for testing rationale and types of tests to order.
Slide 16: Case 2 – 22-year-old Male
•Patient summary: Confusion and grogginess after a night out, potential substance use.
•Testing rationale and appropriate tests to determine substance involvement.
Slide 17: Case 3 – 32-year-old Male
•Patient summary: In IOP program post-drug rehab.
•Testing requirements for program compliance and monitoring.
Randle Adair D.O. PhD
Dr. Adair holds a Bachelor’s in Biology from Georgetown, a PhD in Physiology from Emory, and a medical degree from Nova Southeastern. He completed his Internal Medicine residency at the University of South Alabama and is Board Certified in Internal and Addiction Medicine. He directed the Healthcare Professionals Program at Hazelden Betty Ford in 2013-2014. Currently, he practices at New Mexico Cancer Center, serves on the Presbyterian Provider Wellness Committee, and consults for Turning Point Recovery Center, SouthWest Labs, and other rural addiction centers.