If you get an email proposing you can make big bucks from taking a couple DNA swabs from Medicare beneficiaries, is it too good to be true? Chances are that it is!

The Centers for Medicare & Medicaid Services (CMS) have approved Medicare coverage of certain beneficiary genetic testing. However, you need to be aware that fraudulent behavior, due to solicitation and improper billing, has been identified involving these tests.

We cover the details about the fraud, what consumers should know, and your role in preventing it!

About Medicare Genetic DNA Testing Fraud

Some labs are offering a cheek swab for genetic testing as part of a “free” health screening at events like local health fairs in order to obtain Medicare beneficiaries’ information for identity theft or fraudulent billing purposes.

We’re also aware of third parties offering to pay agents if they help to facilitate Medicare beneficiaries completing genetic tests. Here is an example of what an invitation from a third party looks like.

What Should Medicare Clients Know About Genetic Testing?

Clients should always confirm that their test has been ordered by their doctor, that it’s covered by their plan, and that it’s medically necessary. Also, beneficiaries should never give out their Social Security, Medicare/health plan numbers or banking information to someone they do not know. In addition, your clients should never consent to any lab tests without their doctors’ orders. Please advise your clients to call the customer service number on the back of their ID cards to discuss coverage or other concerns.

If a client asks about the testing, advise them to discuss it with their primary care physician (PCP). A great resource regarding the National Coverage Determination (NCD) for the testing is located on CMS.gov. This is a worthwhile guide to have on hand and for reference as questions come up. The best rule of thumb when discussing any type of testing with your client is to always refer them to their PCP.

Your Role in Preventing Fraud Within Genetic Testing

As an agent, please be wary of any entities that offer you payment for referral of medical services paid for by Medicare. Health screenings, like genetic testing, can be perceived as “cherry picking,” and are therefore prohibited at marketing events. We encourage agents to avoid promotions of this kind. If it is too good to be true, then it probably is, and it’s better to be safe!

Reminder: You can report fraud using the resources below!

  • Call 1-800-MEDICARE (1-800-633-4227)
  • Report it online to the Office of the Inspector General
  • Call the Office of the Inspector General at 1‑800‑HHS‑TIPS (1‑800‑447‑8477)

Ritter’s Stance on Promoting Medicare Genetic DNA Testing

In a post on Insurance Forums, Ritter Insurance Marketing’s President, Craig Ritter, established Ritter’s stance on this topic based on the Anti-Kickback and Criminal Health Care Fraud Statutes.

According to CMS, the Anti-Kickback Statute (AKS) “makes it a crime to knowingly and willfully offer, pay, solicit, or receive any remuneration directly or indirectly to induce or reward referrals of items or services reimbursable by a Federal health care program. When a provider offers, pays, solicits, or receives unlawful remuneration, the provider violates the AKS.”

NOTE: Remuneration includes anything of value, such as cash, hotel stays and meals, free rent, and excessive compensation for medical directorships or consultancies.

Additionally, CMS states the Criminal Health Care Fraud Statute “prohibits knowingly and willfully executing, or attempting to execute, a scheme or artifice in connection with the delivery of or payment for health care benefits, items, or services to either:

  • Defraud any Health Care benefit program
  • Obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the control of, any health care benefit program”

Consequences for violating the Criminal Health Care Fraud Statute can include hefty fines, imprisonment, or both.

Ritter’s president poses that “It is possible to do this [genetic DNA testing] legally, however… any individual representing this would need to be extraordinarily closely aligned to the testing service (like an employee). Further, the agent would be at the mercy of whoever is doing the billing to CMS, and they most likely have no idea whether or not it’s being done compliantly. Finally, given the size of the fees, the likelihood that there is improper billing occurring is, in my opinion, overwhelming.”

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Protect your clients and yourself from genetic testing fraud. If you are ever uncertain about information you have been given, or a promotion you have been asked to take part in, confirm with your agency, the carrier, other agents, or even check out an insurance forum for the latest topics of discussion. A little research will go a long way!