Healthcare Fraud Links

Here is a link to a law firm article that private payer recoupments may occur, as well as government payer recoupments (such as OIG/DOJ).

https://www.hollandhart.com/fraud-and-abuse-in-private-payor-situations

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There are two anti fraud coalitions or organizations:

The first is the National Health Care Anti-fraud Association

https://www.nhcaa.org/

Founded in 1985 by several private health insurers and federal and state government officials, the National Health Care Anti-Fraud Association is the leading national organization focused exclusively on the fight against health care fraud. We are a private-public partnership – our members comprise nearly 90 private health insurers and those public-sector law enforcement and regulatory agencies having jurisdiction over health care fraud committed against both private payers and public programs. Established in 2000, The NHCAA Institute for Health Care Fraud Prevention is a separately incorporated, tax-exempt educational foundation that provides education and training to private- and public-sector health care anti-fraud personnel.  

The second is the Healthcare Fraud Prevention Partnership which I believe is focused on coordinating information and warnings between Federal and State governments and private insurance, regarding healthcare fraud and waste.  HFPP.

https://www.cms.gov/hfpp

https://www.medicaid.gov/state-overviews/scorecard/healthcare-fraud-prevention-partnership-participation/index.html

The HFPP has issued some white papers on laboratory fraud in particular.  Coverage of these, here:

https://www.ebglaw.com/insights/healthcare-fraud-prevention-partnership-issues-a-review-of-clinical-laboratory-services/

For example, see a 16 page 2018 white paper by HFPP about lab fraud.

https://www.cms.gov/files/document/download-clinical-laboratory-services-white-paper.pdf

See a September 2019 DOJ report on genetics fraud:

https://www.justice.gov/opa/pr/federal-law-enforcement-action-involving-fraudulent-genetic-testing-results-charges-against

CPT Code 81408

Quinn later identified that a lot of the mentioned labs, were billing large amounts of code 81408, a $2000 code for sequencing rare genes.   This code rose from almost 0 billing in 2017, to being the largest-billed Medicare code in 2019.   (National 2020 data will be released in about 10/2021).

Here's a block of data from a September 2020 blog of mine about the explosion of 81408 billing.  (Here).

Here's the basics, based on national Part B spending files:

2016 - 361 cases, $490,000 dollars

2017 - 5,817 cases, $9,550,000 dollars

2018 - 62,000 cases, $123,000,000 dollars

2019 - 146,000 cases, $290,000,000 dollars

What code are we talking about?  81408!  This is AMA CPT Tier 2, Level 9, CMS price $2000.

That's 13X dollars allowed growth 2017-2018, and 30X growth 2017-2019 and 590X growth 2016-2019. 

See a series of linked blog by me, about 2019 lab spending, published by me in December 2020.  Here for #1.