Does Medicare Cover Genetic Testing or is it Fraud?

Louisville Metro Government sent this bulletin at 01/27/2015 09:22 AM EST

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SMP
"Protect, Detect, Report"
Empower and assist Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education.

 

 

Does Medicare Cover Genetic Testing or is it Fraud?

 

SMP’s have received reports of groups going into apartment complexes and to senior centers to do educational seminars about genetic testing. During these seminars they promote genetic testing to determine how well your prescriptions work for you.  The people promoting genetic testing to Medicare Beneficiaries could be using this test to commit Medicare fraud and abuse. The Office of the Inspector General in Dallas has an open investigation into this practice.

 

What is Pharmacogenomic Testing? Pharmacogenomic testing is a new tool in medicine that tests genes to determine how individuals may respond to medications. Drugs are metabolized differently in individuals carrying different genes. Certain people have an increased risk for adverse drug reactions and others may need higher doses.

 

Is genetic testing covered by Medicare? Genetic testing is only covered by Medicare when you have signs or symptoms of a disease or condition and your physician says that the test is medically necessary. Genetic tests used to screen for disease risk  or to see how medicines may affect you are not covered by Medicare.  

 

How is genetic testing used to commit Medicare fraud or abuse?

Often, a person offers an educational session to a group of seniors, collects Medicare numbers, performs DNA swabs to test, and then bills Medicare. Medicare does not consider this kind of testing as medically necessary because it is offered to the general population without determining actual need and it is done without the beneficiary’s doctor’s guidance. The person who led the educational session receives  more than $1,100 in payments from Medicare. They are abusing the Medicare system by billing for services that are not reasonable or necessary. It is fraud if they are intentionally billing Medicare for services they know are not necessary.

 

What can you do?

1) If you are approached by someone who wants to perform a DNA or genetic test, decline their services.

2) Only give your Medicare number to individuals inside your healthcare network like your physician’s office, hospital, or pharmacy.

3) If you have been visited by someone taking DNA swabs, contact the KY Senior Medicare Patrol at 1-877-603-6558 to discuss action.