Here are three events in sequence:
- In September 2019, Department of Justice (DOJ) announced a crackdown on a genetic testing fraud that had resulting in $2B of (alleged) fraudulent charges. Press release here. NPR here. Example of follow up news item here at Genomeweb and here at Chicago Sun-Times.
- On September 22 and September 25, 2020, I published a blog on just-released CY2019 Medicare data that I think reveals where some of these fraudulent charges and payments landed, even the CPT codes being used. It looks like the highest paid genetic testing code ($300M) was a largely fraudulent code, and that fraud contributed mightily to the explosion in molecular pathology spending at CMS from $500M in 2017 to $1B in 2018 to nearly $2B in 2019.
- On September 30, 2020, DOJ released another Fraud Press Release, this one for $6B dollars. Here. See also additional fact sheets and links at OIG here.
According to the new September 30, 2020 DOJ press release, a substantial part of the 2020 fraud charges involve telemedicine orders being sold to venders of doubtful genetic tests (or in some cases doubtful DME, etc). The term "genetic test" occurs several times in the new press release. Extract:
Certain defendant telemedicine executives allegedly paid doctors and nurse practitioners to order unnecessary durable medical equipment, genetic and other diagnostic testing, and pain medications, either without any patient interaction or with only a brief telephonic conversation with patients they had never met or seen. Durable medical equipment companies, genetic testing laboratories, and pharmacies then purchased those orders in exchange for illegal kickbacks and bribes and submitted false and fraudulent claims to Medicare...
Coverage by Elise Reuter at MedCity here.
See more about genetic testing fraud in 2019 on this blog - October 6, here.
Is there an "Oliver Stone" Aspect?
I recently rewatched the Oliver Stone movie JFK, so maybe I'm going through a paranoid period.
But I notice that CY2018 payments by CPT to doctors and labs haven't been released yet at CMS, and they're normally released in May at an 18 month delay (e.g. 2018 in May 2020). I emailed CMS and they said yes, they were delayed, for "certain factors." Hmm. Columbo would ask follow-up questions... More on this topic here, including a link to the CMS response.
And recently, I identified clear cut payment errors through a FOIA request to the Palmetto GBA MAC, re MolDx local pricing. Local pricing is specifically a named type of FOIA request at some MACs, so it falls within FOIA.
After I pointed out some errors to Palmetto, I got no response for several days, then a letter from their law firm, that any evidence of payment errors being made by the MAC was a business secret, potentially harmful to the MAC, and should be destroyed. (Read more here). Eek! My Oliver Stone head is really spinning. A main point of FOIA is to get info on errors, potential qui tam cases, and so on.