April 1, 2020
A urologist was sentenced in February 2020 to 71 months in federal prison for submitting fraudulent billings totaling more than $700,000 to Medicare for medically unnecessary and nonexistent treatments and services, sometimes billing for purported patient visits miles apart and occurring at the exact same time.1
The Blue Cross and Blue Shield of Illinois (BCBSIL) Medical Policy for Drug Testing in Pain Management and Substance Use Disorder Monitoring (MED207.154) includes specific requirements for urine drug testing to be considered medically necessary. BCBSIL independently contracted providers are encouraged to review this information to help ensure they are submitting claims that are in alignment with the policy.
BCBSIL is aware of several cases involving medically unnecessary urine drug tests. There have also been instances of contracted providers using out-of-network labs, which is against BCBSIL policy. If you’re aware of an instance of potential fraud, we encourage you to file a report online or call BCBSIL at 800-543-0867 to file a report by phone. All online reports and calls are confidential, and you may remain anonymous.
To view the current medical policy for Urine Drug Testing, refer to the Medical Policy page on our Provider website. Note: Although medical policies can be used as a guide, providers serving HMO members should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual, located in the Standards and Requirements section.
1United States Department of Justice, Urologist Sentenced to Nearly Six Years in Prison for Fraudulent Billings of Nonexistent Patient Visits and Unnecessary Tests, Feb. 24, 2020. https://www.justice.gov/usao-cdca/pr/urologist-sentenced-nearly-six-years-prison-fraudulent-billings-nonexistent-patient