As I have discussed on my main blog in multiple articles, there has been an explosion in genomic test Medicare fraud from 2017 to 2018 to 2019. Much of this uses code 81408, a grabbag code applicable mostly for full sequencing of ultra rare genes such as fatal diseases in infants. At $300M in 2019, this was the highest paid of all molecular CPT codes, but only paid in a handful of states (not paid at all in 5 of 7 MACs as "never medically necessary" in Medicare).
CMS has delayed release of CY2018 provider data by CPT code, data that would normally be released in May. See my September correspondence with CMS here.
On October 14, 2020, I made two submission requests to CMS FOIA. One was for code 81408 spending by NPI in 2018 (probably 10-20 data lines), and the other was all MoPath codes by NPI in 2018 (81162-81599).
Model letter as below.
October 14, 2020
CMS FOIA Officer
Centers for Medicare & Medicaid Services
7500 Security Blvd
Baltimore MD 21244
Dear FOIA Officer:
Under the Freedom of Information Act, Subsection 552, I am requesting access to the following records:
· Since 2014, CMS has annually released data on prior-year utilization of CPT codes, with payment information, for all participating physicians and laboratories.
· The release is usually in May for the calendar year 18 months prior. This represents official agency policy (January 17, 2014, 79 FR 3205) and has a standard website:
· Per correspondence with CMS Medicare Provider Data Team, September 29, 2020, the full public release of CY2018 data has been delayed from May 2020 to time indefinite.
· I request the following limited information via FOIA:
o 2018 payments to physicians and laboratories for CPT CODE RANGES:
§ EITHER 81162-81599
§ OR ELSE (EQUIVALENTLY)
§ I believe this will be an excel spreadsheet of about 2000-2500 liones.
§ Key fields include: NPI, Provider last name, city, state, CPT code range 81162-81599, Number of services, Average Medicare Allowed Amount.
§ Providing all the data fields per each NPI would also be acceptable.
I believe the time to obtain this is reasonable. For 2016 and 2017 data, which is already online at CMS in a cloud database, I can extract this data in a minute or so.
To determine my status for the purpose of fees, I am an individual seeking information for personal use and not commercial use.
In addition, when I identify suspicious payment information I periodically report this to MACs, or CMS, or OIG. Disclosure of the requested information to me is in the public interest because it is likely to contribute significantly to public understanding of the operations or activities of the government and is not primarily in my commercial interest.
I am willing to pay fees to a maximum of $300.
I request information in an electronic format and either email or CD is OK.
I request this information be expedited because of recent reports by OIG, by DOJ, in news media, and on my public blog that there has been a rise in anomalous payments for genetic CPT codes in 2017, 2018, 2019. My work has been covered in two recent trade journal news stories and this reflects current urgency to inform the public concerning actual or alleged Federal Government activity
If you have any questions you may please telephone me at XYZ. My email is XYZ.
Bruce Quinn MD
649 South Mansfield Ave
Los Angeles CA 90036