Genetic testing is a transformative frontier in healthcare, and its promise is undeniable. It is a powerful tool in medicine that can revolutionize patient care. Who wouldn’t want to peek into your own DNA to potentially unlock a world of personalized medicine? It could be like looking into a crystal ball of your own individual health and disease risks. As the advancement and adoption of these technologies grows, so too does the complexity of managing claims for proper payment. The growing popularity of genetic testing has also led to a growing popularity of fraudulent schemes.
What are they?
A genetic test is typically a medical procedure that involves analyzing a sample of blood, saliva, or other tissue. These tests can also provide information about a person’s risk of developing a future disorder or even indicate if they are a carrier for a genetic condition or disease that could be passed on to children. The results can confirm (or rule out) a suspected genetic condition and help guide medication selection or dosage.
Fraudulent genetic testing often exploits the allure of this cutting-edge technology. However, many times these tests are broad panel-based tests that lack much clinical use for the patient’s health status. The rapidly expanding market for genetic testing has also become a target for sophisticated fraudulent schemes that pose significant financial risks to the insurance industry.
What to look for?
Claims for tests that were not medically necessary, not ordered by the patient’s treating physician or were never even performed could be red flags for improper billing and thus cost payors thousands of dollars. So, how do you spot them quickly to stop the improper billing? Some things to keep a watch for are questionable referrals where the ordering physician has no established patient-provider relationship with the individual being tested or for ‘teledoc’ or telemedicine relationships. Also, look for instances of high-volume, high-cost claims from a single provider or a network of providers.
Genetic testing can fall anywhere within these CPT code ranges/categories: 81105-81479: Molecular Pathology Procedures; 81410-81479: Genomic Sequencing Procedures and Other Molecular Multianalyte Assays; 81490-81599: Multianalyte Assays with Algorithmic Analyses; 0002M-0020M: Multianalyte Assay and 0001U-0574U: Proprietary Laboratory Analyses. The most common genetic testing codes associated with improper billing are often Tier 2 molecular pathology codes, 81403-81408. Also associated with improper billing is the unlisted molecular pathology code, 81479. Other areas to data mine for are panel tests codes, 81445-81456, and ensuring these tests are not unbundled.
HCFS has you Covered
Combating fraudulent billing in genetic testing requires a multi-pronged approach. Payors need to leverage advanced data analytics to identify suspicious billing patterns and inappropriate number of services. If you are using the HCFSPlatform™, we got you covered. Our Artificial Intelligence (AI) models identify spikes and other anomalous billing patterns on labs, DME, telehealth and more. We can also help identify new provider billing patterns to help catch any inappropriate billing quickly. Additionally, we have peer comparison and individual tier alerts that identify outliers in genetic testing billing. Some examples of our alerts include:
[2325-20] – OUTLIER – GENETIC TESTING: (PEER COMPARISON)
[2335-01] – MEDICALLY UNNECESSARY, TELEMEDICINE AND GENETIC TESTING
[2660-01] – INAPPROPRIATE NUMBER OF SERVICES, GENETIC TESTING
[2726-01] – UNBUNDLING, FETAL CHROMOSOMAL GENETIC TESTING
[2732-01] – INAPPROPRIATE UNITS, GENETIC TESTING
If you’re not using the HCFSPlatform™ and you’re interested in knowing more, email us at [email protected].
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