South Texas pediatrician settles with OIG over strep test billing

The OIG has agreed to settle with a South Texas pediatric medical clinic that conducted an estimated 23,500 unnecessary tests for strep throat infections. Investigators allege the pediatric group improperly billed the state for $522,901 after running both rapid tests and molecular panels on the same date for the same client or within three days without an additional patient visit.

Both rapid strep tests and molecular panels use different methods to detect the presence of Group A Streptococcus bacteria within 20 minutes, allowing providers to determine if patients should begin treatment. According to Medicaid policy, both tests are mutually exclusive and should not be reimbursed on the same day for the same patient. If one of these preliminary tests comes back negative and a provider still believes strep could be present, they may collect a throat culture which will provide a more accurate diagnosis within 48 hours.

Investigators were also concerned the provider's documentation showed that rapid tests and molecular panels were billed on different dates when the patient had made a single visit to the provider. Medicaid policy states that the date of service must be the date the specimen was collected.

Providers are responsible for following all applicable laws and policies when enrolled to treat clients covered by Medicaid. Failure to follow these policies can result in the OIG pursuing enforcement actions, including administrative, civil and criminal cases for violations of state and federal program laws, policies and rules.