In June 2023, OIG published that Medicare's highest paid genomic test code, 81408, was likely unbelievable and fraudulent from day 1. Here. Practically a billion dollars had gone out from 2018 to 2022, when Medicare payments for 81408 were stopped The code was never billed in the NGS MAC and MolDx regions, and nearly all payments were in Texas (Novitas MAC) and Florida (FCSO MAC).
Payments look like this:
I first referred to 81408 as the "fraudomatic code" in the fall of 2020. Here. Over the next 5 years, I published about a dozen follow up blogs.
Two more insights into the MAC insanity here:
NEW INSANITY #1
Some labs in Florida had huge payments under 81408 in 2022. When that gusher of money stopped in 2023 (bar chart above), the SAME LABS just switched to other costly, unbelievable codes like 81419 (epilepsy gene panel). Here. OMG.
NEW INSANITY #2
This whole time, the program integrity people at CMS left the "Medically unlikely edit" at N=2 for code 81408. If it had been reset to "1", which would have taken five minutes, in 2019 or 2020, CMS would have saved $400M.
Even today, March 2026, the medically reviewed and passable units per claim on 81408 is ... TWO. Here. This is a supervised edit. Someone had to look at this and decide the allowable edits were TWO.
And even after it was a top fraud investigation - surely, by 2022, based on the 2023 OIG publication - nobody at OIG, or a MAC, or a UPIC, or the big CMS program integrity group, could be bothered to reset the MUE units to 0 or 1, saving hundreds of millions of dollars.
In March 2026, it's still...medically allowable as TWO units.
So when I'm interviewed about CMS fraud, like the new CRUSH initative, I say you don't need a supercomputer and the idiocy is a mile deep.
