In a 2019, one of the largest Health Care Fraud schemes ever charged, federal investigations and prosecutions resulted in charges against 35 individuals– CEOs, CFOs and others – with over $2.1 billion in fraudulent claims for cancer genetic testing (CGx). CGx laboratories working with fraudulent telemedicine companies obtained beneficiary information and billed Medicare for expensive cancer genetic tests that were medically unnecessary. In some cases, a single claim totaled over $10,000!1
Variations of this scam have been ongoing since and they show little sign of letting up, as evidenced by this recent healthcare fraud case. A New York physician used patient health information (PHI) gathered at prior COVID-19 testing events in retirement facilities to bill $23 million in fraudulent lab tests, including cancer genetic tests. The physician was not treating any of the patients who attended the COVID-19 testing events and, in many cases, did not even speak to or examine the patients prior to ordering laboratory tests for them such as cancer genetic tests.2
Genetic testing fraud remains an issue despite ongoing valiant educational efforts of the CMS Senior Medicare Patrol (SMP)3, state DHS task forces4, and senior advocate groups 5,6 who work to increase awareness of this scam. Genetic Testing Fraud involves the performance of a cancer screening or pharmacogenetic lab test (a study of how a specific drug is metabolized) that was not medically necessary and/or was not ordered by a beneficiary’s treating physician. The cost of these tests can exceed $10,000 per single claim and are therefore one of the highest reimbursement netting fraud schemes. Laboratories receive inappropriate compensation from payers and providers receive inappropriate kickbacks from the laboratories for services that generate test results that may be of little use to the patient or their treating physician.
Education continues to be an important part of combatting Genetic Testing Fraud, but Health Plans need to monitor claims for excessive frequency of genetic tests. Also, monitor the providers that are ordering these tests, and audit to make sure the tests are medically necessary and performed by the beneficiary’s treating provider. Context4 Healthcare (C4H) offers Fraud Waste and Abuse (FWA) reports which facilitate the monitoring of Genetic Testing Fraud, allowing our user to isolate pertinent claims for audit. For more information on C4H’s solutions, visit our Payment Integrity webpage here: https://www.context4healthcare.com/solutions/medical-payment-integrity/
References:
2. https://www.justice.gov/opa/pr/doctor-convicted-24m-medicare-fraud-scheme
3. https://smpresource.org/medicare-fraud/fraud-schemes/genetic-testing-fraud/
6. https://acl.gov/news-and-events/acl-blog/beware-growing-medicare-scam-free-genetic-testing
