Reviewing Genetic Testing Claims
We see an exorbitant amount of claim lines and dollars paid for genetic tests that don't meet documentation standards. Check out this video to learn more about a particular case reviewed by Integrity Advantage Rockstar Monique Mayes LPN, CPC and gather takeaways to apply to your investigations.
JESSICA: Hi everybody! Thanks for watching and just wanted to “pop on” because, you know, all the fancy influencer people say they’re going to ‘pop on’. So we are ‘popping on’ this morning. My name is Jess. If you don’t know me already, with Integrity Advantage, and I brought my Rockstar med reviewer Monique Mays (yeah girl, I love it!) So we just wanted to talk a little bit about a review that we’ve been doing this week. (And we, by we I mean, she). But we have really had a lot of dialogue internally about this particular review, and it’s for a lab, and specifically, genetic testing which, we know is just a struggle in the industry. In this review, Monique has come up with some really cool stuff. So, we just thought we’d make a quick video and do better generally about trying to share some of the insights that we get from doing these reviews all the time because we do a lot of them. So, without further ado, Monique, take it away.
MONIQUE: Well, thank you very much Jess for the lovely introduction and we did review because it did take a team and I had to reach out to multiple people to help and thank goodness to articles by the OIG, American Cancer Society, and CMS. It helped me get through this and I was able to make it okay. And realize what I was seeing was one of the classic trends of blanket billing and stack billing. The lab did send Evaluation and Management services, the original pathology reports from the facility, and they also sent in a lovely lab requisition form provided to the doctor, that all he had to do is check a little box and multiple genetic panels at that point. That’s all they submitted. So, going through the documentation, there’s a few things I came across that I was like, “hmm, that just doesn’t seem right”. There were no orders for the actual genetic tests or the requisition forms were signed by another physician other than the treating doctor. So, I was like, “okay, where did that come about? Don’t even know who this person is.” The tests that were ordered didn’t even apply to the member, and it wasn’t even going to help them. They just stacked up all this testing, all together. And, the last thing that was most common is there wasn’t a follow up. You didn’t see where the doctor received the results and how it was going to help the member in the treatment.
JESSICA: That’s so interesting because I think more often than not, so, a lot of us just struggle with labs in general, right? So, we know and CMS is very clear that the lab is responsible for having that information that substantiates the “why” they did it, how it was ordered, and how it’s going to impact patient care, and that the results go back to the provider so that it can impact the patient care. And in this one, you actually did get Evaluation and Management documentation, which is unusual really for us to even get.
MONIQUE: It was! I was like, okay, wow, we have the Evaluation and Management note - great. We have a lab note, the requisition - okay. We have the pathology report from the initial facility. Okay, let’s see where this is going to go.
JESSICA: Yeah.
MONIQUE: As I started to dig, I was like, no, classic stack billing.
JESSICA: And so you said there’s three main references that you really felt were helpful. You said CMS, OIG, and American Cancer Society. So we can put those in the comments. If you guys have questions about it, we’re happy to have a discussion but just wanted to share some tidbits of information about what we found and resources because, I don’t know about you guys, but we have lots and lots of resources all over the place. But they do change often, and they take some digging to get to. So, hopefully this helps somebody in their review and streamlines things for you.
MONIQUE: I hope this helps someone and yes, always check your resources. As these new trends come about, the OIG’s on top of it, and they also help lead you to other things just to check in because you never know what’s coming up next.
JESSICA: Awesome, alright. Thanks! Till next time, y’all have a good one. Happy Friday!
MONIQUE: Bye guys!
Integrity Advantage is the way healthcare payers reimagine the value of their fraud, waste and abuse program.
We provide FWA services to payers around the country. If you need a program assessment, program growth strategy, investigations, medical reviews or training support -- reach out today.
We are a certified Women’s Business Enterprise (WBE) and an Economically Disadvantaged Woman Owned Small Business (EDWOSB).
For more information click below, call us at 866-644-7799 or email info@integrityadvantage.com.