When Michael Adams was researching health insurance options in 2023, he had one very specific requirement: coverage for prosthetic limbs.

Adams, 51, lost his right leg to cancer 40 years ago, and he has worn out more legs than he can count. He picked a gold plan on the Colorado health insurance marketplace that covered prosthetics, including microprocessor-controlled knees like the one he has used for many years. That function adds stability and helps prevent falls.

But when his leg needed replacing last January after about five years of everyday use, his new marketplace health plan wouldn’t authorize it. The roughly $50,000 leg with the electronically controlled knee wasn’t medically necessary, the insurer said, even though Colorado law leaves that determination up to the patient’s doctor, and his has prescribed a version of that leg for many years, starting when he had employer-sponsored coverage.

“The electronic prosthetic knee is life-changing,” said Adams, who lives in Lafayette, Colorado, with his wife and two kids. Without it, “it would be like going back to having a wooden leg like I did when I was a kid.” The microprocessor in the knee responds to different surfaces and inclines, stiffening up if it detects movement that indicates its user is falling.

People who need surgery to replace a joint typically don’t encounter similar coverage roadblocks. In 2021, 1.5 million knee or hip joint replacements were performed in United States hospitals and hospital-owned ambulatory facilities, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The median price for a total hip or knee replacement without complications at top orthopedic hospitals was just over $68,000 in 2020, according to one analysis, though health plans often negotiate lower rates.

To people in the amputee community, the coverage disparity amounts to discrimination.

“Insurance covers a knee replacement if it’s covered with skin, but if it’s covered with plastic, it’s not going to cover it,” said Jeffrey Cain, a family physician and former chair of the board of the Amputee Coalition, an advocacy group. Cain wears two prosthetic legs, having lost his after an airplane accident nearly 30 years ago.

AHIP, a trade group for health plans, said health plans generally provide coverage when the prosthetic is determined to be medically necessary, such as to replace a body part or function for walking and day-to-day activity. In practice, though, prosthetic coverage by private health plans varies tremendously, said Ashlie White, chief strategy and programs officer at the Amputee Coalition. Even though coverage for basic prostheses may be included in a plan, “often insurance companies will put caps on the devices and restrictions on the types of devices approved,” White said.

An estimated 2.3 million people are living with limb loss in the U.S., according to an analysis by Avalere, a health care consulting company. That number is expected to as much as double in coming years as people age and a growing number lose limbs to diabetes, trauma, and other medical problems.

Fewer than half of people with limb loss have been prescribed a prosthesis, according to a report by the AHRQ. Plans may deny coverage for prosthetic limbs by claiming they aren’t medically necessary or are experimental devices, even though microprocessor-controlled knees like Adams’ have been in use for decades.

Cain was instrumental in getting passed a 2000 Colorado law that requires insurers to cover prosthetic arms and legs at parity with Medicare, which requires coverage with a 20% coinsurance payment. Since that measure was enacted, about half of states have passed “insurance fairness” laws that require prosthetic coverage on par with other covered medical services in a plan or laws that require coverage of prostheses that enable people to do sports. But these laws apply only to plans regulated by the state. Over half of people with private coverage are in plans not governed by state law.

The Medicare program’s 80% coverage of prosthetic limbs mirrors its coverage for other services. Still, an October report by the Government Accountability Office found that only 30% of beneficiaries who lost a limb in 2016 received a prosthesis in the following three years.

Cost is a factor for many people.

“No matter your coverage, most people have to pay something on that device,” White said. As a result, “many people will be on a payment plan for their device,” she said. Some may take out loans.

The federal Consumer Financial Protection Bureau has proposed a rule that would prohibit lenders from repossessing medical devices such as wheelchairs and prosthetic limbs if people can’t repay their loans.

“It is a replacement limb,” said White, whose organization has heard of several cases in which lenders have repossessed wheelchairs or prostheses. Repossession is “literally a punishment to the individual.”

Adams ultimately owed a coinsurance payment of about $4,000 for his new leg, which reflected his portion of the insurer’s negotiated rate for the knee and foot portion of the leg but did not include the costly part that fits around his stump, which didn’t need replacing. The insurer approved the prosthetic leg on appeal, claiming it had made an administrative error, Adams said.

“We’re fortunate that we’re able to afford that 20%,” said Adams, who is a self-employed leadership consultant.

Leah Kaplan doesn’t have that financial flexibility. Born without a left hand, she did not have a prosthetic limb until a few years ago.

Growing up, “I didn’t want more reasons to be stared at,” said Kaplan, 32, of her decision not to use a prosthesis. A few years ago, the cycling enthusiast got a prosthetic hand specially designed for use with her bike. That device was covered under the health plan she has through her county government job in Spokane, Washington, helping developmentally disabled people transition from school to work.

But when she tried to get approval for a prosthetic hand to use for everyday activities, her health plan turned her down. The myoelectric hand she requested would respond to electrical impulses in her arm that would move the hand to perform certain actions. Without insurance coverage, the hand would cost her just over $46,000, which she said she can’t afford.

Working with her doctor, she has appealed the decision to her insurer and been denied three times. Kaplan said she’s still not sure exactly what the rationale is, except that the insurer has questioned the medical necessity of the prosthetic hand. The next step is to file an appeal with an independent review organization certified by the state insurance commissioner’s office.

A prosthetic hand is not a luxury device, Kaplan said. The prosthetic clinic has ordered the hand and made the customized socket that will fit around the end of her arm. But until insurance coverage is sorted out, she can’t use it.

At this point she feels defeated. “I’ve been waiting for this for so long,” Kaplan said.

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In retrospect, Peggy Dula said, she shouldn’t have taken the ambulance. She was the least injured of the three siblings who were in a car when it was struck by a pickup truck last September. Her daughter had even offered to come to the crash site and pick her up.

Jim Martens, 62, and Cynthia Martens, 63, Peggy’s brother and sister, were more seriously hurt and on their way to the hospital in separate ambulances. Peggy, 55, was told it would be a good idea for her to get checked out, too. So she accepted a ride with a third ambulance crew.

When the wreck happened, the siblings were going to see the horses that Peggy’s daughter trains at a barn west of Peggy’s home in St. Charles, Illinois, about 45 miles outside Chicago. Peggy, who was driving on unfamiliar country roads, pulled into an intersection, mistakenly thinking it was a four-way stop. The truck slammed into the car’s side, spinning it into an electrical box.

Cynthia, who wasn’t wearing a seat belt in the back seat, spent five days in the hospital with a brain bleed, a cracked rib, and a bruised lung. Jim also had fractured ribs, which he learned days later — only after he was back home in Tampa, Florida.

Peggy was “a little stunned” but mostly unhurt as three ambulances descended on the crash site, alerted by 911. She was seen briefly in an emergency room and went home with just a bruised sternum, grateful she had dodged major injury.

Then the bill came.

The Patient: Peggy Dula, 55, who works in a fine jewelry store in Geneva, Illinois.

Total Bill: $3,606 for ambulance services.

Service Provider: Pingree Grove and Countryside Fire Protection District, a fire district serving more than 50 square miles near Elgin, Illinois.

Medical Services: An ambulance ride to a nearby hospital and brief medical evaluation.

What Gives: All three siblings were charged for the same service: “Advanced Life Support Emergency Level 1.” It’s code for transportation by a ground ambulance in response to a 911 call, and it can include medical services as simple as an assessment. All three were also charged a mileage fee. Jim and Cynthia were billed for 15 miles; Peggy was billed for 14 miles. But because they rode in separate ambulances, each from a different nearby fire protection district, they were billed three separate amounts:

• Cynthia was billed $1,250 — $1,100 for life support and $10 per mile — by Burlington Community Fire Protection District.
• Jim was billed $1,415 — $1,265 for life support and $10 per mile — by Hampshire Fire Protection District.
• Peggy was billed $3,606 — $3,186 for life support and $30 per mile — by Pingree Grove and Countryside Fire Protection District.

And although private, for-profit ambulance companies have become notorious for pricey bills, Peggy and her siblings were being billed by taxpayer-funded fire departments.

How could charges for the exact same services vary so widely?

“The simple answer is that these bills are all made up,” said Dr. Karan Chhabra, a surgical resident at Brigham & Women’s Hospital in Boston and a former research fellow at the University of Michigan.

In a 2020 paper published in the journal Health Affairs, Chhabra and his colleagues looked into surprise ambulance bills by analyzing a large national insurer’s claims data from 2013 to 2017. They found that 71% of ambulance rides were out of network, meaning the ambulance companies were not bound by a rate that was negotiated in advance with the insurer and could basically charge whatever they want. Even local fire departments can decline to join local insurance networks.

“It often is the municipalities that are sending some of the most staggering bills and often pursuing them in really aggressive ways,” Chhabra said.

The Pingree Grove and Countryside Fire Protection District’s chief, Kieran Stout, said their charges are in keeping with the federal Ground Emergency Medical Transportation program, which allows some public emergency services to receive supplemental payments for transporting patients on Medicaid, the state-federal health insurance program for people with low incomes. Ambulance services fill out a cost report, and if their average cost per ride is higher than the set rate Medicaid pays, they get paid the difference.

Hampshire Fire Protection District uses the same program to determine the rates they bill, and the Burlington Community Fire Protection District recently began the cost report process as well.

But ambulance services can get their full supplemental amount even if they charge non-Medicaid patients less than that average, said Jim Parker of the University of Illinois Office of Medicaid Innovation. The program is relatively new, though, and some services mistakenly think they need to raise their charges for every patient in order to participate, Parker said.

So for Medicaid patients, the program will pay the difference between the ambulance company’s costs and the standard Medicaid payment.

But for patients with private insurance, like Peggy, the fire protection district bills patients directly for the balance not covered by their insurance, Stout said, a practice known as balance billing. He added that the district only balance-bills patients who live outside the district. In the case of Peggy’s accident, all three siblings lived outside all three districts. (Jim and Cynthia both eventually received settlements from Peggy’s car insurance.)

Congress took aim at balance billing with the No Surprises Act, which went into effect Jan. 1. The law limits the patient’s responsibility for most surprise bills, such as those from an out-of-network anesthesiologist who puts a patient to sleep for surgery at an in-network hospital or for a ride in an air ambulance, almost all of which are privately owned.

But ground ambulances were, controversially, exempt from the law — even though ground ambulance rides are far more common. Of the 1,498,600 ambulance rides in Chhabra’s study, nearly 98% were by ground ambulances.

Chhabra suspects ground ambulances got special treatment because federal lawmakers felt a need to “tread lightly” around their relationships with local governments. Many ambulance services are run by municipalities and may need to bring in enough revenue to pay their expenses.

“This might be what they need to do in order to cover their own budget,” Chhabra said.

Resolution: Peggy said her insurer, BlueCross BlueShield of Illinois, deemed the “reasonable and customary rate” for the services Peggy received to be $1,892. It applied $400.23 to her deductible and then paid $895.06 — 60%, according to the cost-sharing requirement of Peggy’s plan. Pingree Grove and Countryside then billed Peggy for the balance of their charge, $2,710.94.

Peggy challenged the balance with Paramedic Billing Services, the company that handles the district’s billing, citing her siblings’ much lower charges. “Needless to say, I am speechless at the outrageously high bill I received,” Peggy wrote. “I am willing to pay $354.94, which (with my insurance payments) equals the amount my sister is being charged for the exact same ride.”

Paramedic Billing Services Vice President Michael Tillman said patients must dispute charges directly with the ambulance service. Peggy said her subsequent calls to Pingree Grove and Countryside have gone unanswered.

To demonstrate her good faith in the absence of an answer, Peggy said, she sent $20 to Paramedic Billing Services. She received a letter back with a coupon saying she needed to set up a payment plan for the full amount, so she sent another $20. In June, she received a letter from a collection agency saying she owed $2,670.94.

“They really weren’t working with me, were they?” she said.

In a statement, a spokesperson for Peggy’s insurer, John Simley, said the insurer pays for ambulance services according to the terms of a member’s plan. “Certain ambulance companies may charge amounts far in excess of the benefits” a member’s plan provides, Simley said. “This sometimes subjects members to pay the balance of ambulance services not covered by their benefit coverage.”

The Takeaway: Getting into an ambulance involves financial risk. Your health may demand it. But your wallet may suffer. So understand your options.

Obviously, if you’re seriously hurt in an accident, you have no way to figure out whether the ambulance that turns up is in your network.

However, if you feel well — just a bit banged up or with a laceration from a car crash or a fall from a bike — remember this: You do not have to get in just because an ambulance rolls up. They arrive because they’ve been informed of an accident by police or because a bystander has called 911.

Related Links

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• The Case of the $489,000 Air Ambulance Ride

Calling a friend or car service like Uber or Lyft to drive you to a doctor, urgent care, or a hospital emergency room could save you thousands of dollars. (And please do seek timely follow-up care on any possible head injury.)

It’s also worth knowing whether your local fire department’s ambulance service is in your insurance network, information that might influence your decision.

Of course, this all raises the larger question of whether ambulance operations should be revenue generators at all.

“Or should it just be something that’s a public good that we pay for out of our taxes like the fire department or police department,” Chhabra said, “none of whom I’ve ever heard of anybody getting a bill from?”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

A western New York health insurance provider for seniors and the CEO of its medical analytics arm have agreed to pay a total of up to $100 million to settle Justice Department allegations of fraudulent billing for health conditions that were exaggerated or didn’t exist.

Independent Health Association of Buffalo, which operates two Medicare Advantage plans, will pay up to $98 million. Betsy Gaffney, CEO of medical records review company DxID, will pay $2 million, according to the settlement agreement. Neither admitted wrongdoing.

“Today’s result sends a clear message to the Medicare Advantage community that the United States will take appropriate action against those who knowingly submit inflated claims for reimbursement,” Michael Granston, a DOJ deputy assistant attorney general, said in announcing the settlement on Dec. 20.

Frank Sava, a spokesperson for Independent Health, said in a statement: “The assertions by the DOJ are allegations only, and there has been no determination of liability. This settlement is not an admission of any wrongdoing; it instead allows us to avoid the further disruption, expense, and uncertainty of litigation in a matter that has lingered for over a decade.”

Under the settlement, Independent Health will make “guaranteed payments” of $34.5 million in installments from 2024 through 2028. Whether it pays the maximum amount in the settlement will depend on the health plan’s financial performance.

Michael Ronickher, an attorney for whistleblower Teresa Ross, called the settlement “historic,” saying it was the largest payment yet by a health plan based solely on a whistleblower’s fraud allegations. It also was one of the first to accuse a data mining firm of helping a health plan overcharge.

The settlement is the latest in a whirl of whistleblower actions alleging billing fraud by a Medicare Advantage insurer. Medicare Advantage plans are private health plans that cover more than 33 million members, making up over half of all people eligible for Medicare. They are expected to grow further under the incoming Trump administration.

But as Medicare Advantage has gained popularity, regulators at the federal Centers for Medicare & Medicaid Services have struggled to prevent health plans from exaggerating how sick patients are to boost their revenues.

Whistleblowers such as Ross, a former medical coding professional, have helped the government claw back hundreds of millions of dollars in overpayments tied to alleged coding abuses. Ross will receive at least $8.2 million, according to the Justice Department.

Ross said that CMS “created a bounty” for health plans that added medical diagnosis codes as they reviewed patients’ charts — and whether those codes were accurate or not “didn’t seem to bother some people.”

“Billions of dollars are being paid out by CMS for diagnoses that don’t exist,” Ross told KFF Health News in an interview.

Data Mining

DOJ’s civil complaint, filed in September 2021, was unusual in targeting a data analytics venture — and its top executive — for allegedly ginning up bogus payments.

DxID specialized in mining electronic medical records to capture new diagnoses for patients — pocketing up to 20% of the money it generated for the health plan, according to the suit, which said Independent Health used the firm from 2010 through 2017. DxID shut down in 2021.

Gaffney pitched its services to Medicare Advantage plans as “too attractive to pass up,” according to the Justice Department complaint.

“There is no upfront fee, we don’t get paid until you get paid and we work on a percentage of the actual proven recoveries,” Gaffney said, according to the complaint. Timothy Hoover, an attorney for Gaffney, said in a statement that the settlement “is not an admission of any liability by Ms. Gaffney. The settlement simply resolves a dispute and provides closure to the parties.”

‘A Ton of Money’

CMS uses a complex formula that pays health plans higher rates for sicker patients and less for people in good health. Health plans must retain medical records that document all diagnoses they highlight for reimbursement.

Independent Health violated those rules by billing Medicare for a range of medical conditions that either were exaggerated or not supported by patient medical files, such as billing for treating chronic depression that had been resolved, according to the complaint. In one case, an 87-year-old man was coded as having “major depressive disorder” even though his medical records indicated the problem was “transient,” according to the complaint.

DxID also cited chronic kidney disease or renal failure “in the absence of any documentation suggesting that a patient suffered from those conditions,” according to the complaint. Past conditions, such as heart attacks, that required no current treatment, also were coded, according to the DOJ.

The suit alleges that Gaffney said renal failure diagnoses were “worth a ton of money to IH [Independent Health] and the majority of people (over) 70 have it at some level.”

Ross filed the whistleblower case in 2012 against Group Health Cooperative in Seattle, one of the nation’s oldest managed-care groups.

Ross, a former medical coding manager there, alleged that DxID submitted more than $30 million in disease claims — many of which were not valid — on behalf of Group Health for 2010 and 2011. For instance, Ross alleged that the plan billed for “major depression” in a patient described by his doctor as having an “amazingly sunny disposition.”

Group Health, now known as the Kaiser Foundation Health Plan of Washington, denied wrongdoing. But it settled the civil case in November 2020 by agreeing to pay $6.3 million. The DOJ filed a second complaint in 2021, against Independent Health, which also used DxID’s services.

Ross said she lost her job after her suit became public in 2019 and was unable to secure another one in the medical coding field.

“It was rough at times, but we got through it,” she said. Ross, 60, said she is now “happily retired.”

False Claims

Whistleblowers sue under the False Claims Act, a federal law dating to the Civil War that allows private citizens to expose fraud against the government and share in any recovery.

At least two dozen such suits, some dating to 2009, have targeted Medicare Advantage plans for overstating the severity of medical conditions, a practice known in the industry as “upcoding.” Previous settlements from such suits have totaled more than $600 million.

The whistleblowers have played a key role in holding health insurers accountable.

While dozens of CMS audits have concluded that health plans overcharged the government, the agency has done little to recoup money for the U.S. Treasury.

In a surprise action in late January 2023, CMS announced that it would settle for a fraction of the estimated tens of millions of dollars in overpayments uncovered through its audits dating to 2011 and not impose major financial penalties on health plans until a round of audits for 2018 payments, which have yet to be done. Exactly how much plans will end up paying back is unclear.

“I think CMS should be doing more,” said Max Voldman, an attorney who represents Ross.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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After Elizabeth Moreno had back surgery in late 2015, her surgeon prescribed an opioid painkiller and a follow-up drug test that seemed routine — until the lab slapped her with a bill for $17,850.

A Houston lab had tested her urine sample for a constellation of legal and illicit drugs, many of which, Moreno said, she had never heard of, let alone taken.

“I was totally confused. I didn’t know how I was going to pay this,” said Moreno, 30, who is finishing a degree in education at Texas State University in San Marcos and is pregnant with twins.

Related: ‘Bill Of The Month’: A College Student’s $17,850 Drug Test

Her bill shows that Sunset Labs LLC charged $4,675 to check her urine for a slew of different types of opioids: $2,975 for benzodiazepines, a class of drugs for treating anxiety, and $1,700 more for amphetamines. Tests to detect cocaine, marijuana and phencyclidine, an illegal hallucinogenic drug also known as PCP or angel dust, added $1,275 more.

The lab also billed $850 to test for buprenorphine, a drug used to treat opioid addiction, and tacked on an $850 fee for two tests to verify that nobody had tampered with her urine specimen.

Total bill: $17,850 for lab tests that her insurer, Blue Cross and Blue Shield of Texas, refused to cover, apparently because the lab was not in her insurance network. The insurer sent Moreno an “explanation of benefits” that says it would have valued the work at just $100.92.

Moreno’s father, in a complaint to the Texas attorney general’s office about the bill, identified the Houston surgeon who ordered the costly test as Dr. Stephen Esses. His office told Kaiser Health News the surgeon would have no comment.

Sunset Labs is part of a network of pain clinics and other medical businesses founded by Houston anesthesiologist Phillip C. Phan, according to Texas secretary of state filings and court records. Court records say Phan’s companies also own the facility where Moreno had her operation.

Three experts interviewed by KHN said the lab grossly overcharged; they also doubted the need for the test.

“This just blows my mind,” said Jennifer Bolen, a former federal prosecutor and lab and pain management consultant. “It’s very high and incredibly out of the norm.”

Dan Bowerman, a medical fraud expert, called the lab bill “outrageous” and “unconscionable” and said it should have prompted an investigation.

“Sounds real fishy,” added Charles Root, a veteran industry adviser. He wondered if the lab had “misplaced the decimal point,” because such a test should cost a few hundred dollars, tops.

The lab disagrees.

Sunset’s billings “are in line with the charges of competing out-of-network labs in the geographical area,” lab attorney Justo Mendez said in an emailed statement.

Mendez said pain doctors agree that extensive urine testing is “the best course of action” and that a lab “is not in the position” to question tests ordered by a doctor.

Urine testing for patients with chronic pain has grown explosively over the past decade amid a rising death toll from opioid abuse. Pain doctors say drug testing helps them make sure patients are taking the drugs as prescribed and not mixing them with illegal substances.

Yet the testing boom costs billions of dollars annually and has raised concerns that some labs and doctors run urine tests needlessly — or charge exorbitant rates — to boost profits.

Some insurers have refused to pay, which can leave patients like Moreno threatened with ruinously high bills they had no idea they had incurred.

“Surprise bills larded with unexpected expenses and little explanation inflict sticker shock on vulnerable patients,” said James Quiggle, communications director of the Coalition Against Insurance Fraud, whose members include insurers, consumer groups and government agencies. Quiggle said many “puffed-up bills straddle a fine line between abuse and outright fraud.”

Moreno said her insurance covered the disc removal surgery in December 2015. She said the operation went well and she weaned off the hydrocodone pain pills. To her surprise, on a second return about a month later, the surgeon’s office asked her to leave a urine sample.

“I didn’t think anything of it,” Moreno said of the test. “I said fine, whatever.”

More than a year later, she said, the lab phoned while she was driving and asked her to pay the $17,850 bill. The lab then sent her an invoice, dated March 10, 2017, which states: “[B]ased upon information from your health plan, you owe the amount shown.”

Luckily, her father, Dr. Paul Davis, was visiting her in Texas at the time. Davis, 66, is a retired family practice doctor from Findlay, Ohio.

Davis doubted the need for the test, not to mention what he thought was a sky-high price. He said the University of Findlay, where he helped train physician assistants, gave applicants a basic drug test at a cost of $174, while the local juvenile courts in Ohio paid $10 for a simple drug screen.

Fearing it would ruin his daughter’s credit scores, Davis said, he called Sunset and settled the bill in April 2017 by paying $5,000, which he said he now regrets. The lab sent Moreno a receipt that said it discounted her bill because of “financial need/hardship.”

Asked for comment, Blue Cross spokesman James Campbell said he couldn’t discuss a specific case but noted:

”We are disappointed as well as concerned about transparency whenever [any] member is surprised by an excessive charge for a seemingly routine service or received services that may not have been medically necessary.”

Campbell also said the lab was out-of-network and “we do not control how much they charge for services rendered.” The insurer encourages patients to confirm that all medical care they seek comes from medical providers in the Blue Cross network, he added.

Prices for urine tests can vary widely depending upon complexity and the technology used. Some doctors’ offices use a simple cup test, which can detect several classes of drugs on the spot. These tests rarely cost more than $200, and typically much less.

Bills climb higher when labs check for levels of multiple drugs and bill for each one, a practice insurers argue is seldom medically justified. But even labs sued by insurers alleging wildly excessive testing typically have billed $9,000 or less, court records show. One insurer sued a lab for charging $1,845 for a drug test, for instance.

Davis said Sunset Labs ignored his requests for a full explanation of the charges. In May, he filed a written complaint about the bill with the Texas attorney general’s office that included a copy of the bill and accused the lab of “price gouging of staggering proportions.”

“Young people just starting out, such as my daughter, may not have the ability to pay and this could result in damaged credit ratings or even bankruptcy,” he wrote.

Davis got a letter back from Attorney General Ken Paxton, who said the office would “review the information.” A spokesperson for Paxton told KHN: “We have received complaints about that business, but we can’t comment on anything else.” Sunset attorney Mendez said the lab is “not aware” of any such complaints.

In an interview, Davis also questioned the need for his daughter’s urine test because she received opioids only for a short period and the results would have had no impact on her treatment. In his complaint to the attorney general, Davis said the surgeon told him he ordered the tests because he feared possible retribution from the state medical licensing board for not testing patients who had been prescribed an opioid. The Texas Medical Board doesn’t require urine tests for patients receiving opioids for short-term pain, said spokesman Jarrett Schneider. That’s a “question of independent medical judgment as to whether the physician believes a drug test should be required,” he said.

Bad Reviews

Sunset Labs has an “F” rating with the Houston Better Business Bureau, which on its website posts an August 2017 complaint from a patient charged $16,150 for a urine test.

“This is not covered under my health insurance so I am expected to pay this excessive bill,” the complaint reads.

A second website that publishes government billing numbers of doctors and medical businesses includes a comment section with more than a dozen negative “reviews,” mostly complaints that the lab slammed patients with thousands of dollars in fees their insurers balked at paying.

In a pair of lawsuits filed in 2015, three doctors seeking to quit working at pain clinics operated by Phan accused the facilities of improper billing practices, including unnecessary urine testing. The doctors said they feared losing their medical licenses unless they severed their ties.

In one suit, Drs. Purvi Patel and Lance LaFleur also alleged that the pain clinics “pressured” doctors to overprescribe medical gear and genetic tests to insured patients “regardless of medical necessity.” The case did not go forward because the doctors did not pursue it. Neither doctor would comment.

In the second legal case, pain specialist Dr. Baominh Vinh said he resigned in April 2015 “based on certain questionable business practices … that are inconsistent with my ethical boundaries.” Vinh also alleged urine testing was overused. In a countersuit against Vinh, the pain clinics called his allegations a “falsehood” to justify violation of his employment contract.

The parties settled in March of last year. Terms are confidential, but a lawyer for the pain clinics said Vinh paid money to the company “and not vice versa.”

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