Medicare Corner
What Happens if Medicare Denies the Genetic Test Claims?
You could be responsible for the entire cost of the test! The average is $9,000-$11,000. How Your Senior Medicare Patrol (SMP) Can Help Your local 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. PCOA is your state Senior Medicare Patrol (SMP): For assistance, call (520) 790-7262 Medicare And Genetic Testing When are Genetic Tests Covered?
Example Charges for One Cheek Swab How are Fraudsters Benefiting from Genetic Testing Fraud? See the chart for why this is becoming more prevalent. These services are not free. Each cheek swab could potentially make the company thousands of dollars by billing Medicare and/or you for services that were not needed.
1. When someone has stage III or IV cancer 2. When the test is medically reasonable and necessary Federal regulations define medical necessity as “services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” 3. When it is ordered by a treating physician Federal regulations define a treating physician as “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.” 4. When one or more coverage requirements are met for colorectal cancer genetic screening There is no other Medicare coverage for genetic testing as a screening service. 5. When a treating physician orders the test as a diagnostic service and uses the results to manage the patient’s condition
This project was supported in part by grant number 90MPPG0022, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects with government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official ACL policy
December 2022, Never Too Late | Page 7
Pima Council on Aging
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