Monthly Archives: February 2015

WARNING: Individuals promoting genetic testing of Medicare Patients may be committing Medicare fraud and abuse.

by Barbara Parrott McGinity, LMSW

What is Pharmacogenomic Testing?
Pharmacogenomic testing is a new tool in medicine. It is the testing of certain genes to determine how any given individual will respond to specific medications. Drugs are metabolized slowly in individuals carrying genetic polymorphisms that reduce enzyme activity, and these individuals are at an increased risk for adverse drug reactions or therapeutic failure. Alternatively, a genetic polymorphism that increases metabolism could result in ineffective drug treatment.

Genetic testing covered by Medicare?
As long as Medicare is the patient’s primary insurance, and the test is deemed medically necessary, it is currently covered by Medicare with no co-pay or deducible. Title XVIII of the Social Security Act, Section 1862(a) (1) (A) states “…no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis and treatment of illness or injury…”.

Furthermore, it has been a longstanding CMS policy that “tests that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury are not covered unless explicitly authorized by statute.”

Screening services, such as pre-symptomatic genetic tests and services, or those used to detect an undiagnosed disease or disease predisposition, are not a Medicare benefit and are not covered by Medicare. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk for and/or of a condition unless the risk assessment clearly and directly effects the management of the patient.

How Could this be Medicare fraud or abuse?
When an individual offers to provide an educational session to a group of seniors, takes their Medicare number, then does a DNA swab, this does not meet Medicare’s criteria of medical necessity. They are offering a service to the general population without determining actual need and they are doing it outside the guidance of the Medicare beneficiary’s own physician.

The group will bill Medicare for services that do not meet medical necessity and do not have a referring physician familiar with the patient’s health needs. The amount they will receive from Medicare is over $1,100. They are abusing the Medicare system by billing for services that are not reasonable or necessary. They could potentially be committing fraud by intentionally billing Medicare for services they know are not necessary.

What can you do?
1) If you are approached by someone, decline their services because you should not give access to your seniors to individuals who take their personal information. Then call and report this to the Texas Senior Medicare Patrol.
2) If you have already been visited by someone taking DNA swabs, contact the Texas Senior Medicare Patrol to discuss action at 1-888-341-6187,

BBB Advice on What to Do After a Data Breach Compromises Your Identity

Better Business Bureau (BBB) has some suggestions for consumers concerned that their personal identifying information (PII) may have been compromised by a data breach. PII includes name, address, Social Security number, date of birth, and other information that can be used for identity theft.

When a data breach happens, companies often set up separate websites with information for customers, but the BBB recommends that consumers always go to a company’s main website first and follow links from there. Scammers often take advantage of data breaches and subsequent confusion to set up spoof websites and send phishing emails.
BBB offers the following suggestions for consumers concerned that their PII has been stolen:

1. Do not take a “wait and see” approach as you may have done with breaches involving credit card data. You must act quickly. Breaches involving Social Security numbers have the potential to be far more detrimental to victims, and the damage can be difficult to repair.

2. Consider taking a preemptive strike by freezing your credit reports. This will not impact existing credit cards and financial accounts, but will create a roadblock for thieves seeking to create fraudulent accounts using your personal information.

3. At a minimum, if you know your Social Security number has been compromised, place a fraud alert on your credit reports. While less effective than a freeze, this will provide an extra layer of protection. Click here to learn more about security freezes and fraud alerts.

4. Take advantage of any free credit monitoring services being offered by the company to breach victims. While this is not a preventative measure, this will alert you to new accounts or inquiries using your Social Security number so that you can act quickly to repair the damage.

5. Vigilance is key. Regularly check your credit reports at annualcreditreport.com for unauthorized charges or other signs of fraud. (NOTE: This is the only free credit report option authorized by the Federal Trade Commission.)

6. For more information and complete step-by-step guidance on repairing the damage caused by identity theft, visit the FTC’s identity theft resources.

7. Expect that scammers will take advantage of this data breach to send out phishing emails and other messages that appear to be from Anthem, a credit bureau or other legitimate companies. Do not click on links from any email, text or social media messages about this or any other data breach.