One of the biggest health frauds still exists


Nine doctors and a practicing nurse were among the 35 people charged with various crimes associated with fraudulent genetic testing for cancer in which the U.S. Department of Justice (DoJ) he called “one of the largest health fraud schemes ever charged.”

His various companies collectively charged Medicare and other federal health programs for $ 2.1 billion for unnecessary genetic testing for cancer, which billed up to $ 23,000 a piece, according to criminal charges issued in September 2019.

Despite this success almost two years ago, when several government agencies acted in a coordinated strike, evidence fraud continues.

Last month, consumers filed 17 complaints about genetic testing, primarily for cancer testing, that provided information about the risk of developing malignancies, to the American Retirement Association (AARP) Fraud Watch Network, according to Amy Nofziger, fraud director. victim support to non-profit organizations.

This measure is about the same as it was two years ago, when AARP first appeared issued a report on cancer genetic testing fraud.

“It’s still happening,” Nofziger said Medscape Medical News.

He added that many Medicare frauds are not reported because beneficiaries are not asked to pay for services and do not know they are victims.

But in what may be a new wrinkle, scammers are also billing seniors.

Amy Nofziger

“What’s been interesting about this scam is that once Medicare started denying some of those charges, the criminals would send the bills to the Medicare beneficiary,” Nofziger said. “We had people telling us they were charging thousands of dollars for the DNA cancer kit.”

Initially, the elderly used to approach through health fairs, centers for the elderly and telemarketing and were offered a “free” test, which gathers DNA with a quick cotton on the cheek which is then sent by mail to the laboratory.

Now, with the COVID-19 pandemic, the request is made primarily through telemarketing calls or online announcements (with swab kits that are mailed to participants).

However, many seniors have reported that they did not even receive test results or obtain incomprehensible lab readings, according to the DoJ.

Medicare only pays for the genetic cancer tests they meet national regulations, which greatly restrict its use to cancer patients.

Coverage requires that tests be performed in a laboratory certified for clinical laboratory improvement (CLIA) amendments, ordered by a treating physician, and used for suspected mutations (inherited or related to aging), spokesman for the Centers for Medicare & Medicaid Services (CMS) Medscape Medical News.

Even with these parameters, Medicare payments for genetic testing went from $ 480 million in 2015 to $ 1.1 billion in 2018, at Reuters analysis Found. It was this suspicious increase in costs that triggered Operation Double Helix, the federal government’s investigation into related claims and alleged scams.

Scams in the shadow of a major military outpost

The alleged cancer genetic testing fraud was not a centralized effort, but spread across the United States and charges were handed down for separate operations in several states.

Schemes varied by location, but generally involved the inclusion of a physician or telemedicine company, as well as testing labs and some type of Medicare beneficiary recruitment operation.

Medscape Medical News reviewed the indictment of two Texas doctors to find out about the alleged fraud.

In 2019, Sekhar Rao, MD, an interventionist radiologist, and Vinay Parameswara, MD, an internist, both from Travis County, were charged with welfare fraud and conspiracy to commit welfare fraud. In exchange for counterattacks, doctors “signed” orders for cancer genetic screening tests, as well as toxicology tests for the ADAR (Alcoholism & Drug Addiction Recovery) group, an outpatient toxicology testing laboratory in Killeen, near Fort Hood, a U.S. Army facility. Both doctors reportedly provided the ADAR group with signature stamps that employees used to order the tests. According to the indictment, false diagnostic codes such as “malignant lip neoplasm” were introduced in the claims to try to gain acceptance and payment.

ADAR group staff allegedly lured the beneficiaries of Tricare, which is the Army’s health plan and federal program, with Walmart gift cards to provide urine (toxicology) and saliva (cancer genetics) samples and they collected samples from up to 200 beneficiaries a day. .

The two doctors did not “examine or talk to the beneficiaries for whom they signed trial orders” and “there was no doctor-patient relationship between the doctors and those beneficiaries,” the indictment says, noting that this violates the federal coverage.

The two doctors allegedly filed “false and fraudulent claims in federal health care programs” for genetic cancer testing and toxicology testing worth approximately $ 36 million, approximately from May 2014 to June 2016. turn, Tricare paid approximately $ 4.8 million in claims to the scammers. The indictment included lists of charges billed for evidence, which ranged from $ 2,500 to $ 11,000.

The ADAR group owner recruited Rao and Parameswara to be “medical directors” through online job offers, according to his indictment. The two doctors were paid between $ 6,000 and $ 8,000 a month for their involvement in the operation.

Rao’s lawyer, Mick Mickelson, said so Medscape Medical News that the interventional radiologist is on trial and is not currently practicing medicine. “The allegation against him is that, in exchange for a fee, he allowed a medical provider to issue genetic detection prescriptions that were not medically necessary or were not otherwise indicated,” Mickelson summarized.

Parameswara’s lawyer did not respond to any requests for comment.

Perfect storm

AARP’s Nofziger described the events of the past five years or so that prepared the United States for almost unprecedented medical fraud allegations.

“It was kind of a perfect storm for criminals to come in and blow people up,” he commented.

Nofziger noted that in recent years, current events, such as news about the availability of 23andMe, the first direct DNA test to the consumer, and television commercials for swab-based testing (e.g. for the Allergies) increased the profile and general acceptance of the scientific concepts involved in the alleged scam.

In addition, in 2018, CMS changed its ID cards, which may have facilitated the execution of the fraud, Nofziger commented.

Social Security numbers were removed from Medicare ID cards and replaced with specific Medicare numbers. That measure, which was required by law and aimed to discourage identity theft, made older people “a little more informal in giving their information,” he said, adding that ID numbers they are essential for filing claims.

Finally, Nofziger said the ubiquity and “emotionality” of cancer in family trees allowed the schemes.

“What would you do if someone called you and told you you could do a free cancer screening test?” he asked rhetorically, suggesting that supply has a strong appeal to many seniors.

Next Great Frontier

Medicare and Medicaid fraud is big business in the United States. Annually, CMS loses one estimated at $ 75 billion due to a fraud in health care, said Lou Saccoccio, executive director of the National Anti-Fraud Association of Health.

“We were probably one of the first agencies to detect this [cancer genetics test fraud]”AARP has a unique profile in the United States when it comes to fraud, as it receives more than 500 phone calls related to the day through its helpline. The nonprofit organization is l ‘Only national provider of financial crime support services for the elderly,’ she said.

In 2019, after AARP issued its report on the said fraud, “we were flooded [with complaints from seniors], “she said.

The Office of the Inspector General, a division of the Department of Health and Human Services, also noted the problem and issued a fraud alert on genetic testing for cancer in 2019, as well as individual states.

Two years ago, Brian Benczkowski, Deputy Attorney General of the Criminal Division of the United States Department of Justice called genetic testing of the elderly “the next big frontier in the application of federal health fraud.”

ASCO guidance

The American Society of Clinical Oncology (ASCO) has one Web page to help doctors understand what is permissible and billable with testing.

“Medicare does not currently provide coverage for genetic testing in people without a personal history of cancer,” ASCO explains on its website, which includes common CPT billing codes for genetic risk assessment, as well as a summary of genetic parameters. Medicare and Medicaid coverage.

ASCO notes that Medicare will cover genetic testing BRCA1 i BRCA2, Lynch syndrome and other biomarkers in cancer-free patients under certain conditions.

ASCO also notes that the tests, also known as multigenic panel tests for cancer susceptibility, have gray areas and related risks.

“Multigenic panels increase the likelihood of identifying genetic factors that predispose individuals to cancer risk, but these tests can also identify unexpected risks of cancer or other diseases, mutations with unclear cancer care recommendations, and variants of uncertain importance, ”says ASCO.

The organization recognizes that inadequate medical intervention and psychological stress are possible outcomes.

The price of testing is also an issue, ASCO says patient website: “Genetic testing can be expensive. It’s particularly expensive if health insurance doesn’t pay for it.”

Although the parties involved in the alleged scams go on trial, AARP’s Nofziger said the authors of the cancer genetic testing schemes can now change their marketing sequences to genetic testing for heart disease, as this last is a complication related to COVID-19 and therefore more salable. “Scammers follow the headlines,” he said.

Nick Mulcahy is an oncology-focused senior journalist for Medscape, who can be contacted [email protected] on Twitter: @MulcahyNick

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