Tag Archives: drug testing

Choosing the Right Drug-Testing Courses

A drug-free workplace is a safer place to work, provided the drug testers themselves have passed the test; provided they have done the coursework; provided they have taken the right courses to do their jobs with accuracy and ease; provided the provider of the coursework is himself an expert—a professional who seeks to train like-minded individuals, whose commitment to the collection and testing process is supreme. Finding that person, and taking his courses, is critical not only as a matter of compliance or as an issue of law but as an example of integrity: so that employers can trust the results—and employees need not mistrust the collectors—because excellence governs the process.

For insurers, it is not enough for clients to follow the rules or to obey the letter of the law. Not if companies ignore the spirit of the law. Not if doing the minimum the law requires enforces the law of unintended consequences in which the quality of the coursework differs—and too many testers take mediocre courses—making it difficult if not impossible to have faith in the process.

According to Andrew Easler of DrugTestingCourses.com: “States that discount the cost of workers’ compensation insurance in exchange for voluntary drug-free workplace policies: There is a reason these states mandate the methods of sample collection and the procedures testers must follow. Quality training creates standards for chain of custody—and chain of custody all but eliminates the risk of specimen adulteration or substitution.”

See also: Wellness Industry’s No-Good, Very Bad Year  

I agree with that analysis, as it speaks to the economic and educational values of this subject.

I agree because we can neither afford nor accept uncertainty to cloud the drug testing process. If we have no confidence in the training men and women receive, if the sole measure of consistency is the frequent inconsistency of how and when someone gathers samples, if the absence of quality makes the process moot—if any or all of these things persist, businesses cannot survive, and workers cannot succeed. Statistics prove this point, while attempts by employees to cheat the system highlight the dangers too many companies face.

That these attempts exist is not an indictment against workers, whose addictions are an expression of personal pain and private suffering. It is, however, a statement of failure about the quality, or lack thereof, regarding the online courses of some drug testing instructors.

The monetary effects of this system manifest themselves in increased sick days, lost productivity and lower morale, among many other things. The moral effects are a separate challenge altogether, because they are a threat to the very nature of trust.

How can a company do business, after all, if it cannot earn the trust of insurers or enjoy the loyalty of consumers?

How can insurers issue policies and collect premiums if they have no faith in the drug testing process?

See also: A Test Case on Sanity of Drug Prices  

Restoring that faith—no longer having to rely on faith alone—starts with quality coursework, which is a test case in how to train individuals to do quality drug testing, free of haphazard decisions and hazardous decision makers.

The right coursework is the right course to follow, period.

10 Tools to Cut Workers’ Comp Costs

1. Implement a fraud-abatement program

Employee education helps defer fraud, so creating a fraud abatement campaign that fits for your industry and includes education of employees can have a significant impact on the number of questionable claims filed. Communicate regularly with your employees about workers’ compensation and eliminate misconceptions by explaining what it is and how it works. Consider using social networks, flyers, posters, employee newsletters and guest speakers to spotlight workers’ compensation fraud as a serious crime. The guest speaker can be a representative from your insurance carrier’s special investigation unit (SIU), a local law enforcement representative who is focused on workers’ comp fraud (such as a Department of Insurance fraud investigator or deputy district attorney handling prosecutions in the fraud unit) or a representative of your contracted SIU partner. Provide employees a mechanism to report fraud anonymously, such as a fraud hotline or email system, so they can easily report suspicions. Encourage employees to share information.  Insurance fraud is a felony in most states, and employers should demonstrate zero tolerance, with timely investigation of claims and reporting of suspicious claims to law enforcement.

2. Use sound hiring practices

The best defense is a strong offense. Conduct thorough pre-employment background checks to eliminate candidates who are unable to perform the job or not a good fit. If you have questions about anything you find in a background investigation, ask the applicant to explain.  It is a good idea to hire an investigative agency to assist, especially if you do business in multiple states, to ensure the investigations abide by all local, state and federal laws and regulations. Consider pre-employment drug testing; drug users can be unsafe workers and are more likely to file false claims to obtain money for drugs.

3. Pave the way for return to work

Communicate to employees that every attempt will be made to get injured employees healthy again and returned to work. Prepare a comprehensive, written, return-to-work plan, with detailed job descriptions that include temporary or alternative duties, and communicate that plan to appropriate persons. The functional job description is one of the best tools for identifying the discrete and unique duties, responsibilities and accountabilities associated with varying positions. The functional job description is a part of a continuing process throughout the entire employment relationship and should track and reflect changes in organization structure, tasks, accountabilities, skills and requirements. The functional job description should document the minimum job requirements and preferred qualifications of each position (including education, experience, licenses, certificates, physical requirements and work day/hours). This description can be used in conjunction with hiring practices to ensure the applicant has the ability to perform the job. Functional descriptions are also important for medical providers to use in determining return to work following an injury, including whether the employee can return to work full duty or in a modified capacity.

4. Surveillance video equipment

Monitoring is a proven spoiler of workplace crimes.  Consider both covert and overt monitoring, depending on the job site, type of claims filed and privacy concerns. If an injury is alleged, quickly secure the video and forward to your investigative partner to secure the evidence, log chain of custody and provide copies as needed. If the video does not match the employee’s description of the injury, create a strategy to share copies of the video with medical providers to ensure that only warranted benefits are obtained. Communicate with your claim professional, defense attorney and investigative partner to determine the best plan of action. For example, additional investigation may be warranted before putting the video into evidence, such as surveillance to document the employee’s current physical abilities or a recorded statement or deposition by the injured worker to memorialize his account of the injury. Your team will create a strategy to appropriately leverage the video in handling the claim and potential fraud.

5. Have a plan for when an industrial injury occurs

Provide training to leadership on how to respond when an industrial injury occurs. Respond immediately to any reported injury or rumor of potential injury. Promptly recommend your predetermined medical provider to the injured employee. A detailed description of the accident and injury should be obtained, and any relevant workplace evidence should be preserved. Have a professional investigation conducted as soon as possible. A timely investigation can help ensure the injured worker receives the appropriate benefits at the appropriate time. A thorough investigation can include statements by the injured worker, witness statements, scene inspection, photographic evidence, the securing of workplace equipment or other evidence. An investigation can also include a search of public records, criminal and civil court records, Department of Motor Vehicle records, a prior claims search, the securing of copies of records such as police report, 9-1-1 call record, OSHA report or other, as applicable. The investigation can identify potential subrogation so that the claim professional and defense attorney can pursue potential third-party liability. The investigation will also highlight suspicions; consequently, having a professional, third-party investigative agency conduct the initial compensability investigation is a critical tool in preventing fraud.

6. Familiarize yourself with investigative tools

Investigation of claims provides many benefits on workers’ comp costs and is especially critical for claims that have “red flags,” to ensure that only warranted benefits are administered and that potential abuse or fraud is identified early. Technological advances have provided new investigative tools as well as enhanced the capabilities of “old-school” investigative solutions. Background investigations, Internet searches, social-network monitoring and database searches are cost-effective investigations that can be conducted quickly and provide a plethora of valuable information. Information found on social networking often includes current activities, past behavior, hobbies, interests, sports, clubs, association, vacations and more. This evidence can include both photographic evidence and written information. If the injured worker is not improving despite medical treatment, consider having surveillance conducted to determine the level of physical abilities, limitations and restrictions. Surveillance evidence provides the best impact. The investigative agency should conduct a pre-surveillance investigation that includes searching social networking sites, databases, public records and DMV records. While currently the use of drones is not legal in most states, this is technology that may be incorporated into the investigative toolbox in the near future. Field investigations are important to determine compensability of a claim, so obtain recorded statements from the injured worker and any potential witnesses. Remember that “witnesses” are not only people who may have seen the injury occur, but people who may have information about the injured worker’s prior injuries, prior claims, hobbies, other employment, activities, etc. This may include co-workers who work near the injured worker, eat lunch together, share a carpool or take breaks together. Question potential witnesses if they personally obtained photographs or video of the subject incident or scene, as this is often the case given the widespread use of smartphones. Medical facility searches and pharmaceutical searches locate prior medical records and pharmaceutical history, which can help determine compensability and apportionment, identify potential drug abuse and ensure that only warranted benefits are paid.

7. Implement a safety program

Make workplace safety a priority; a safe workplace makes fake or exaggerated injuries harder to legitimize. Hold regular safety meetings and remind employees about workplace safety through social media, posters, flyers or employee newsletters. Consider a program that rewards workers for meeting safety milestones. Encourage employees to identify potential safety issues and share their ideas. To reduce repetitive injury claims, provide onsite ergonomics solutions to ensure employees are performing their duties the correct way. Encourage prompt reporting of injuries to immediately identify and resolve any problem that may contribute to workplace injuries.

8. Create an Experienced and Specialized Team

Build a strong and dedicated team to manage your workers’ compensation claims. Your team should include experienced claim management professionals, specialized legal resources, risk managers, a licensed investigative agency specialized in workers’ compensation and an SIU with certified fraud specialists (either internal with your insurance carrier or contracted directly). Communicate with your claim professional and ensure that he is actively identifying red flags and investigating your claims in a timely fashion. Partner with a licensed investigative agency that is experienced in your industry. If insured with a carrier, communicate with the carrier’s SIU to ensure that your claims are being reviewed by fraud specialists. If you are self-insured or in a high-deductible program, partner with an investigative company that has a successful SIU. Communicate with your team regularly to ensure active handling of claims, identify suspicious claims early and build effective strategies to leverage investigative evidence to stop unwarranted benefits and fight fraud.

9. Listen

Listening to employees can provide valuable information. The injured worker may have provided key information before and after the injury. Was the employee complaining before the alleged injury about work, physical pain or personal problems? Was he disgruntled, turned down for a promotion or had a change in job duties, supervisor or responsibilities? Did the injured worker talk about family problems such as health issues, additional family responsibilities or other personal situations? This information may be relevant and should be shared with the claim team. Listen after a workplace injury and throughout the claims process, as rumors of misrepresentations or foul play may filter through the workplace. Keeping an ear to the grapevine may help in weighing a claim’s validity. Have an “open-door” policy and encourage employees to share information and report suspicions.

10. Be Familiar With the Red Flags of Workers’ Comp Fraud

  • Injury reported late or on a Monday or following time off
  • Exaggerated details about incident or symptoms
  • Co-worker skepticism or different versions of the incident
  • Disgruntled, soon-to-retire, soon-to-strike, facing layoff or involved in seasonal work that is about to end
  • Unexplained or excessive time off prior to claimed injury
  • Has a history of short-term employment
  • New on the job, and injury is unwitnessed or suspicious
  • Experiencing financial difficulties or domestic problems before filing the claim
  • Recently purchased a private disability policy
  • Submitted employment application with misrepresentation(s)
  • First notification of injury or claim made after employee is terminated or laid off
  • Reported immediately after days off or alleged injury around date of a denied vacation request
  • History of substance abuse, prior injuries or prior accidents, especially soft-tissue injuries
  • Is known to participate in high-risk activity such as snowboarding, drag racing or boxing
  • Suspicion or tip of unreported work, cash work, seeking other employment or self-employed
  • Failed to report the injury in a timely manner or “forgot” to report critical details
  • History of reporting injuries, especially soft-tissue injuries
  • Other family members also receiving workers’ comp benefits or other “social insurance” benefits
  • Is unusually familiar with workers’ comp claim handling procedures and laws
  • Is consistently uncooperative, refuses to sign documents or submits documents with cross-outs
  • Information that employee is active or may be exaggerating limitations
  • In-house surveillance, tip or information indicating the injury may be non-industrial or not legitimate
  • Refuses to provide a statement or sign a medical release
  • Moves out of state or country shortly after filing claim
  • Protests about returning to work or changes provider once released to work
  • Details of accident are vague or contradictory, have inconsistencies or are not credible
  • Reported injury has same factors of other claims reported by co-workers, especially in the same time period
  • Denial or failure to report prior injury or medical treatment
  • Suspected altering of checks, off-work slips, prescriptions, or suspicious mileage reimbursement
  • Dramatizes physical condition or draws attention to collar, brace or other supportive devices
  • Is observed moving normally or without medical devices (collar, brace, cane, etc.)

Urine Drug Testing Must Get Smarter

Medical treatment guidelines, such as the American College of Occupational and Environmental Medicine and the Work Loss Data Institute’s Official Disability Guidelines, recommend urine drug testing (UDT) for monitoring injured workers who are prescribed opioids. Yet studies show that few physicians actually order the tests.

There are a variety of concerns about UDT, including its potential overuse, underuse, effectiveness and cost. The guidelines are fairly nonspecific in terms of the frequency and type of testing that are most appropriate for injured workers. The fact is, all UDTs are not created equal and should not be used interchangeably.

Immunoassay tests, for example, are preferred when simply trying to detect the presence or absence of illegal drugs in a person’s system. More sophisticated tests, such as liquid chromatography, may be more suitable for clinical applications. They are far more accurate than immunoassay tests, can identify parent medication and metabolites and can identify specific medications, rather than just drug classes.

The differences in the types of drug testing have important ramifications for patients. For example, inappropriate or insufficient testing can put injured workers at risk for drug overdoses.

“The type of testing clinicians use should depend on the purpose,” said Steve Passik, vice president of Clinical Research and Advocacy for San Diego-based Millennium Health. “The immunoassay test comes from a forensic application and vocational application. In those settings, only the most egregious offenders are meant to be caught.”

Job seekers, workers involved in workplace accidents, and athletes are among those typically subject to forensic tests. For them, immunoassay testing is appropriate and is based on the Mandatory Guidelines for Federal Workplace Drug Testing Programs, developed by the U.S. Department of Health and Human Services.

Because much of UDT today has its roots in forensic applications, the methods and mindsets of simple immunoassay testing are often used in clinical settings. These tests are subject to a high number of false positives; therefore, only positive results are typically sent for confirmatory testing to avoid falsely accusing people of drug use that might have dire consequences, such as job loss.

“This is problematic,” Passik said. “An injured worker who is using drugs and has a false negative result is potentially at risk if the physician uses a forensic mindset and only confirms positive test results. If the injured worker’s pain medications are mixed with whatever drugs he may be abusing, he could suffer an overdose. Or, his addiction could worsen since it is not being detected by the workers’ comp claims administrator.”

Immunoassay tests are generally cheap, fast and readily available. However, they are not designed for, nor are they very effective for, many clinical applications on their own.

“Take a worker who is being prescribed pain medications and is overusing them. The worker runs out of his or her medication and then borrows some from a friend or family member and even further supplements by abusing heroin when these are unavailable,” Passik said. “If his result on an immunoassay test comes back positive for an opioid, this lends a false sense of security that it is, in fact, the prescribed opioid that caused the result. This result is actually a ‘clinical false negative’ for the non-prescribed opioid and heroin. If the clinician has a forensic mindset that sets out simply to catch people but not falsely accuse them, the testing would end there.”

Another example might be seen in the worker prescribed an opioid for pain but also using cocaine who knows not to use it within two to three days of doctors’ visits to avoid testing positive on the immunoassay. The immunoassay test would likely yield a false negative, and testing would, again, end there. “This worker could be quite vulnerable and might even engage in the type of self-deception whereby he convinces himself that he has no drug problem because he can stop in time to produce a negative specimen for cocaine, ”said Passik.

The mixing of cocaine or heroin and prescribed and borrowed pain medications would make the worker susceptible to an overdose and to other drug interactions or to triggering his addiction. But the medical provider in this case would have no idea the person is abusing drugs.

“That’s the rub,” Passik said. “If I were using UDT in a worker’s comp setting, I would have a more flexible policy that allows the provider to use his clinical judgment to determine whether to send either positive or negative results from immunoassay tests to a lab for confirmation testing, or simply skip the immunoassay test and go straight to the lab.”

Immunoassay tests often produce false negative results because of the high cutoff levels that prevent the tests from detecting low levels of medications. They may also fail to detect opioid-like medications such as tramadol and tapentadol, as well as synthetic opioids such as fentanyl and methadone.

False positive results also occur, because certain immunoassay tests are subject to cross-reactivity from other medications and over-the-counter drugs and may produce inaccurate results. And there is a limited specificity for certain medications within a class.

Liquid chromatography tests, on the other hand, enable detection of a much more expansive list of drugs. This is significant, as virtually all injured workers on opioid therapy would be expected to test positive on a drug screening. The liquid chromatography test could detect which opioid was present in the injured worker’s system and at which levels.

In a 2012 study that analyzed results for point-of-care tests using immunoassay in physicians’ offices or labs, Millennium Health found 27% of the test results were incorrectly identified as positive for oxycodone/oxymorphone. The low sensitivity of immunoassay tests can mistakenly identify codeine, morphine or hydrocodone as the same drugs. Similarly, the study results showed the immunoassay tests missed the identification of benzodiazepines in 39% of the results.

One example of clinical chromatography is liquid chromatography tandem mass spectrometry (LC/MS-MS). These tests are far more accurate than immunoassay tests, can identify parent medication and metabolites and identify specific medications, rather than just drug classes.

“Professionals can now accurately test with both great sensitivity and specificity to understand whether patients are taking their prescribed medication, avoiding the use of non-prescribed licit controlled substances and whether or not they are using illicit drugs, which allows for better clinical decision making,” Passik explained. “LC/MS-MS results are now rapidly available to clinicians, allowing for a much greater integration of these results into clinical practice.”

In fact, Passik says much of the growth in the use of LC/MS-MS in recent years is because of the speed with which results can now be obtained, often within 24 hours.

In terms of drug monitoring for injured workers, Passik says immunoassay testing alone does not provide the physician with an accurate basis on which to make good clinical decisions. These tests may be positive for opiates – which, if the person has been prescribed opiates, would be expected.

“In this case, a positive result would need to be sent to the lab to confirm that the opioid detected in the test was solely the medication prescribed and there are no other licit — or illicit — drugs present. The immunoassay positive result by itself doesn’t provide enough information,” Passik said. “However, if the worker is well known to the prescriber and has a long history of UDTs showing he is taking his medications as prescribed, the provider might decide the immunoassay test result will suffice at that point. But, again, it would need to be in the context of appropriate results of UDTs and a clinical exam that do not suggest otherwise.”

Beyond the confusion about the types of UDT, a handful of unscrupulous clinicians are overusing the tests by performing them in their offices or labs they own, regardless of the patient’s risk factors for abuse or overdose. Payers are overcharged by these providers, as they do more testing than is necessary and charge for the initial test, analysis and confirmatory test (because virtually all tests on injured workers receiving opioid therapy would be positive), resulting in three separate bills.

There are also questions surrounding the frequency with which these tests should be performed on a given injured worker. Passik and other experts say the frequency of the tests should be determined by a medical provider based on the injured worker’s risk factors. An injured worker who is depressed, male, a smoker and has a personal or family history of substance abuse would likely warrant more frequent testing than someone with no known risk factors who is fully cooperating with those handling his claims and is eager to do, or is already doing, light duty work. It’s a tough call, and, so far, it is not an exact science.

“If the patient is older and has no history of addiction or other risk factors, you would probably test her a couple of times a year,” Passik said. “But a coal miner in southeastern Kentucky who has been traumatized from an accident, has addiction history in his family, lives in an area where he can make money [by selling the drugs] — that’s a high risk person who likely needs to get tested more often. Most people fall in between, so it’s best to rely on the clinician’s extensive training and individual assessments of their patients and potential risk factors to consider when developing a treatment plan.”

Part of the decision making on the part of medical providers involves figuring out strategies to integrate the two methods of testing, immunoassay and chromatography – “specificity when you need it and the frequency when needed so you can do it in the most cost effective fashion,” Passik said. “The tests should be integrated in a smart way.”

The nature of workplace injuries is such that more testing up front may be required. “Unfortunately, workers’ compensation is heavily loaded with high-risk patients,” Passik said. “They tend to be younger, traumatized because they are injured, and suffer from depression — all of which are risk factors for addiction.”

The best advice for practitioners is to look for thorough documentation from providers, communicate with all parties, especially the injured worker, and become informed on the type and frequency of UDTs performed for each injured worker.

25 Axioms Of Medical Care In The Workers Compensation System

  1. The right medical care at the right time is always in the best interest of the injured worker and almost always will result in the lowest claims costs.
  2. The right medical care at the right time will (almost always) result in an earlier return to work with less permanent residual disability.
  3. Evidence-based medicine is the right care for the legitimately injured workers. (There is a hierarchy on how to apply evidence-based medicine).
  4. To control worker's compensation medical costs requires both a fee schedule and an ability to control the frequency and the appropriateness of treatment. One without the others usually results in massive increase in medical costs for the system.
  5. The medical treatment fee schedule should be clear, easy to use, accurate and reflect the latest technology.
  6. A fee-for-service system may result in incentives for physicians to over-treat, inappropriately.
  7. In many jurisdictions Worker's Compensation is generally the last fee-for-service system.
  1. As long as workers compensation uses a fee-for-service system, medical utilization review is needed to make sure that the physicians will treat adhering to evidence-based medicine.
  2. Pharmacy utilization is problematic because of the “Medicalization” of the general population. (Medicalization is the direct advertising of symptoms and diagnoses to the general population by drug manufacturers, resulting in an overuse and/or misuse of some types of drugs and therapies).
  3. There is a significant problem with “off label use” of drugs in the worker's compensation system. (Off Label is the use of a drug for treatment that was not the reason for its approval from the FDA).
  4. Medical decisions should be made by medical professionals. Most Workers' Compensation judges, attorneys, and claims adjusters have little to no formal medical training and are not medical professionals.
  5. Poorly (inappropriate) placed incentives will result in poor medical outcomes. (There are several studies that demonstrate that allowing physicians to do self-referrals or to dispense pharmacy goods from their offices will usually result in a utilization of unnecessary services or inappropriate usage of drugs).
  6. Even if the doctor is not dispensing the drugs, opiates require regular visits to the doctor for renewal of the prescription and also may involve expensive drug testing; so there is a financial interest on the part of some doctors to prescribe opiates.
  7. Some physicians who prescribe opiates do not fully appreciate the addictive power of the drugs that they are using or the difficulty in detoxing the patients.
  8. There are currently enough treating physicians and specialty physicians in most urban areas; however there are not enough physicians (treating, orthopedic or neurosurgeons, etc.) in the rural areas to meet the demand. This problem will only get worse as the population ages and more doctors retire. It will also get worse if physicians leave workers' compensation due to the demand for their services due to the implementation of the federal universal health care programs.
  9. Many surgeons and other physicians want to perform their craft (do surgery, provide injections, etc.). They truly believe that their surgery or injections will work even if the prior treatments have not been successful or if current evidence-based medicine says surgery is not appropriate.
  10. Every patient looks like a good candidate for an MRI when there is an MRI machine in the doctor's office.
  11. Not every person with a surgical or potentially surgical condition is a good surgical candidate. Though pre-surgical psychiatric evaluations are required for spinal cord stimulators (post spine surgery), the same is not true for many other surgeries.
  12. It is difficult for a patient who is in intractable pain to believe that strong medications (including opiates) are not appropriate or are not good.
  13. It is difficult for a patient who is in intractable pain to believe that not having back surgery will have the same ultimate result as having surgery when the surgeon is saying (with confidence) that the surgery will cure all. Even though current evidence-based medicine says differently.
  14. Because “doing something is better than doing nothing” when the patient is in intractable pain, if the surgeon says surgery will not be successful, the injured worker will attempt to find someone who will say that the surgery “will be more successful than not having surgery,” and will then attempt to have the surgery.
  15. Patient advocacy is the application of appropriate treatment and patient encouragement that allows the patient to remain as functional and productive as possible.
  16. Patient advocacy does not always mean the pursuit of treatment a patient desires.
  17. Patient advocacy may require the physician to decline to do the treatment sought by the patient when that treatment is inappropriate.
  18. In Workers'Compensation, there are many (known and unknown) underlying non-industrial, psyche/social issues that may hinder or completely stop optimum medical recovery.