Genetic testing scams are rapidly becoming one of the top major fraud schemes across the country.
Medicare beneficiaries are being targeted by unscrupulous telemarketers, door-to-door salesmen, and seemingly helpful people manning the booth at a local health fair who claim that Medicare will pay for it and the test will be free. Don’t fall for it and certainly don’t hand over your Medicare card or agree to pay if the test is not prescribed by your doctor. Remember, if it sounds too good to be true, it probably is.
EXAMPLES OF GENETIC TESTING FRAUD
•A company or individual offers you “free” or “at no cost to you” testing without a treating physician’s order. The company then bills Medicare (usually thousands of dollars) for a broad range of genetic tests that you did not request or possibly even receive.
•A company or individual uses “telemedicine” to offer testing to you over the phone and arranges for an unrelated physician or “teledoc” to order the test.
•A company or individual sends you a kit for genetic testing and asks that you return the test with your Medicare number.
•A company or individual tries to bill Medicare for pharmacogenomic tests (to determine how you metabolize drugs) that are neither covered by Medicare or apply to you.
Here are just a few questions to ask when encountering potential genetic testing scams along with answers that provide information and guidance about how to handle each situation.
Q. Did the person/provider offer you a genetic test to screen for cancer or another condition?
A. Decline the offer. With so much interest in genetic tests as early warning systems for cancer, it makes sense that beneficiaries and others would wonder if Medicare covers genetic testing as a screening and prevention benefit. The answer, with one exception, is no. Although Medicare covers many genetic tests for diagnostic use, it only covers one genetic test to screen for cancer.
Since October 2014, Medicare Part B has paid for the Cologuard test, manufactured by Exact Sciences Corp of Madison, Wisconsin, to screen specifically for colorectal cancer. Scammers often refer to these tests as hereditary cancer screenings, DNA screenings, cancer screenings, genetic testing, pharmacological testing, Alzheimer’s screenings, dementia screenings, heart disease screenings, gene mutation screenings, genetic marker screenings, etc. Regardless of what the person calls it remember Medicare does not cover genetic tests to screen for cancer — except for one colorectal cancer DNA screening test from “Cologuard.”
Q. Did the person/provider say that Medicare covers genetic tests at no cost to you?
A. The tests are usually described as being available and useful for a wide range of people regardless of their health condition. Scammers will try to tell you that a person’s insurance will cover the tests for “free.” They make this claim because Medicare pays for diagnostic lab tests according to a fee schedule, with no deductible or coinsurance costs for patients, but only when medically necessary. The tests are only medically necessary with a treating physician’s order. If Medicare denies the tests, you could be charged the entire amount, which could easily run $9,000 to $11,000.
Q. Did the person/provider say that Medicare covers this as a preventative test?
A. As mentioned earlier, Medicare does not cover genetic tests to screen for cancer as a preventative benefit, with only one exception for a colorectal cancer DNA screening test.
Q. Did the person/provider tell you what they are doing the genetic test for or which cancers they are testing for?
A. Medicare does not cover genetic tests for beneficiaries who do not have any symptoms or diagnoses of cancer. Medicare rules specifically state the following:n “Tests for screening purposes that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury are not covered as explicitly authorized by statute.”
Q. Did the person/provider tell you who would be following up with you regarding the results? Did the provider read your results and, if needed, use them to set up a treatment plan?
A. Lab tests like this must be ordered by a treating physician. Medicare rules state:
“All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.”
Q. Did the person/provider use scare tactics such as “your prescriptions could kill you” or “to prevent cancer,” claiming cancer and using the wrong prescription as the biggest killers of seniors?
A. If you have concerns about how your body is metabolizing your prescriptions or if you are at risk for cancer, you should talk with your health care provider, who should be aware of the prescriptions that you are on and your family’s medical history.
Your Pennsylvania Senior Medicare Patrol (SMP) is ready to provide you with the information you need to PROTECT yourself from Medicare fraud, errors, and abuse; DETECT potential fraud, errors, and abuse; and REPORT your concerns. SMPs and their trained volunteers help educate and empower Medicare beneficiaries in the fight against health care fraud. Your SMP can help you with your questions, concerns, or complaints about potential fraud and abuse issues. To receive local services in Pennsylvania visit or call (800) 356-3606.
(Joel Mekler is a certified senior adviser. Send him your Medicare questions at [email protected].)