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,

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