Centers for Medicare & Medicaid Services’ (CMS’s) Oversight of Medicare Payments for the Highest Paid Molecular Pathology Genetic Test Was Not Adequate To Reduce the Risk of up to $888 Million in Improper Payments

Excerpt:  “Prior [Office of Inspector General (OIG)] work identified increased spending on Medicare Part B genetic testing, as well as fraudulent billing of genetic tests. Although there may be legitimate reasons for the increased spending, the increases indicate the potential for improper payments. Our prior analysis showed that, for 2016 through 2019, Current Procedural Terminology (CPT) code 81408 was the genetic-testing procedure code with the second highest total Part B payments and was the molecular pathology procedure (a type of genetic test) with the highest Medicare payment amount ($2,000). This CPT code may be billed when testing for multiple genes associated with rare diseases. Because these diseases generally manifest in childhood, the genes associated with them would not generally be tested for in the Medicare population, which is predominantly 65 years of age and older. Therefore, there is a risk of Medicare improper payments for this CPT code.”