Preventing Genetic Testing Fraud: 5 Actions for Health Plans

The following is a guest article by Erin Rutzler, Vice President of Fraud, Waste, and Abuse at Cotiviti
In Delaware, more than 250 Medicare patients underwent unnecessary genetic testing based on telehealth consultations that often lasted less than two minutes—costing Medicare thousands of dollars per patient. Meanwhile, an emerging scheme for fraudulent and unnecessary cardiovascular and cancer genetic testing allegedly resulted in $174 million in false and fraudulent Medicare claims.
These are just two examples of what the Healthcare Fraud Prevention Partnership describes as a surge in fraud, waste and abuse associated with genetic testing claims. Such scenarios demand vigilance from health plans and new approaches to preventing inappropriate billing before it starts.
Genetic Testing Schemes Put Dollars and Health at Risk
Globally, the genetic testing market is expected to reach $17.6 billion by 2026, driven in part by direct-to-consumer testing for health risks such as breast cancer and physician orders for prenatal testing, tumor molecular profiling and sequencing to diagnose rare disease. In this environment, “hybrid labs”—those that perform both direct-to-consumer genetic testing and traditional, medical-grade testing—are proliferating.
Now, as new genetic tests unlock advancements that can improve health and well-being—even for those suffering from the rarest of genetic conditions—the risk for fraud, waste and abuse in genetic testing is high. In 2021, a ...

Source: EMR and HIPAA - May 5, 2023 Category: Information Technology Authors: Guest Author Tags: Administration Genomics-Precision Medicine Health IT Company Healthcare IT Regulations Revenue Cycle Management Cotiviti CPT Codes Erin Rutzler Fraud Waste and Abuse FWA Genetic Testing Genetic Testing Fraud Healthcare Fraud Prev Source Type: blogs