BQ CRuSH COMMENT

 I have two comments relative to Genomics initiatives proposed within CRUSH.  The first involves nationalization of the MOLDX program.   The second involves stopping fraudulent genomics payments while not adding pointless burdens to the legitimate laboratory industry.  Before making those two comments, I will first briefly summarize Medicare genomics fraud.

1) MEDICARE GENOMICS FRAUD

In 2014, the AMA CPT issued a new coding system for genomic tests, creating hundreds of codes, some valued >$1000, many with no relevance to Medicare-page patients.  Because the codes often had no relevance to Medicare, MACs issued no LCDs on them.  A key difference between recent DME fraud and Genomics fraud is that DME fraud involves services (equipment) that was potentially valid - like electric wheelchairs.  The genomics fraud generally involved services that were intrinsically nonsensical in the Medicare population, making Medicare's vulnerability more outrageous.   In the first fraud phrase, illicit labs mostly in TX and FL billing >$6000 per patient on absurd genetic tests, usually code 81408 (x2 = $2000 x 2) and adjacent codes.  TX and FL apparently had no edits on this and autopaid > $1B in a few years. See my March 10 blog, https://www.discoveriesinhealthpolicy.com/2026/03/the-crush-initiative-and-medicares-bone.html

OIG and others forced a crackdow on codes in the 81408 series by CY2023.  However, it is possible to find labs that billed tens of millions on fraudulent codes in CY2022 and merely switched seamlessly to other, nearby nonsensical costly codes in 2023 and 2024 (see blog).  Uncontrolled codes included 81419, 81440, 81443. Again, many hundreds of millions of dollars flowed out uncontroled (see blog for bar charts to 2024).   

The level of nonsense includes Medicare's stopgap medically unlikelyl edits which allowed some of these nonsensical codes to be paid in multiples of 2 (from 2018 to 2026 ongoing). If someone had merely set the unikely edit to N=1, half a billion dollars would have been saved for 5 minutes work.  

At least in genomics fraud, these problems went on for years and were absurd.  AI and PhD computer science was not needed, a ten year old with Excel could have found this.

COMMENT ONE - MOLDX

Had the MolDx program been in place in TX and FL over a billion, likely nearly 2 billion, would have been saved 2018-2024.  MolDx is not strictly an antifraud program, but involves close review of the laboratory and its molecular validation and quality procedures, which most fraudulent labs could not pass.  In addition, MolDx had extensive dedicated staff to tracking coding and expenditures and policies, and nonsensical claims would have been stopped in weeks or a couple months, not 5-8 years.  Even implementing MolDx as-is would be highly effective and adding modest anti-fraud detection controls would close off remaining problems.   

COMMENT TWO - NORMAL GENOMICS LABS

Legitimate genomic  testing has risen greatly in importance, especially in cancer, the #2 cause of death in the Medicare population.  The legitimate lab industry is vastly different than the fraudulent genomics industry.  Fraud can be stopped - cut 99% - by measures that do not impact the legitimate lab industry.  The lab industry sometimes suffers under document collection - if asked to provide reams of distant hospital and clinician paperwork as part of audits and prior auth, requests that are nearly impossible to comply with may show a so-called error rate (sic) that is artifactual (relative to valid tests for real cancer patients).   

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Comment Tracking Number: mnd-h702-jjm1