Wednesday, January 11, 2023

Genomeweb Story on Indicted Lab - Novitas Bizarrely Excessive Payments for Code 81408 (Rare Full Length Genes)

 On January 9, 2023, Genomeweb published a short article about a lab indicted by DOJ for excessive or kick-back related genetic testing - here.  DOJ press release here.

DOJ adds, "An indictment is merely an allegation. All defendants are presumed innocent until proven guilty beyond a reasonable doubt in a court of law."

If you google the name of the lab and the term NPI, you get its NPI - in Lewisville, TX, as the article indicates.   In CMS records for 2019 payments by CPT code and lab - here - you find there were $21,840,000 in payments allowed by the Novitas MAC.

Half the payments - 47% - were for code 81408, rare full-length gene sequencing, and that code, billed twice for every patient.   I've discussed the absurdity of large scale payments of code 81408 for every Medicare patient, and usually in gene pairs, for several years.   These huge payments to great numbers of labs in the South like Texas and Florida never made one particle of sense and could have been detected by a ten year old, and went on year after year, from 2018 well into 2021, at the least, overall reaching the high hundreds of millions of dollars paid.  

This issue was covered in detail by Kelsy Ketchum of 360DX on December 8, 2022.


The lab shown is unusual in billing and being paid over $500,000 for PLA codes 0031U, 0032U, that belong exclusively to Mayo Clinic, which bills in Minnesota to the NGS MAC, so the codes shouldn't be payable at all in Texas (unless there was a biospecimen referral program in place back and forth to Mayo).