New news. I've reported in great detail for several full years on the massive and insane spending on Tier 2 codes at Novitas and FCSO MACs, the only MACs that pay in any real amounts for the high level Tier 2 codes like 81408. I've called 81408 the "fraudomatic' code," with hundreds and hundreds of millions of dollars in visible payments in CMS database. This extends from 2018 to 2021, at the least.
81408 fraud is different than, say, wheelchair fraud. A given beneficiary, or 50 of them, MIGHT need electric wheelchairs. But no elderly Medicare beneficiary has ever never 2 each of all 9 Tier 2 codes, on one day. Codes, for example, for genes that cause epilepsy in babies. The gusher of colossal funds wastage continued rampant, despite my public blogs, several major public trade journal articles, also here, and multiple DOJ prosecuted cases. And it was hardly rocket science to avoid this billion dollars wasted: NGS MACs and MolDx MACs were able to avoid the problem easily and completely.
Here at last is the scathing OIG report.
Novitas' new LCD for oncology allows a range of payable circumstances of 81408 (incuding at least one for pediatric disease), so fraudulent providers could happily comply and submit claims that were autopaid, unless stopped for records, something Novitas hasn't done in the past.
The report focuses laser like on 81408, not emphasizing the key feature, that if a lab billed 81408, and usually billed a stack of ALL THE TIER 2 CODES, in nearly every case. This enormously adds a greater level of lunacy to an already preposterous claim (for 81408 itself).