Cardiovascular Genetic Testing Fraud Tip Sheet Wisconsin

Genetic testing scams quickly emerged in 2019 targeting cancer screening and pharmacogenetics
(medication metabolization). The latest growing genetic testing fraud trend focuses on cardiovascular
genetic testing. Scammers are offering Medicare beneficiaries cheek swabs for genetic testing to obtain
their Medicare information for fraudulent billing purposes or possibly medical identity theft.

What is Cardiovascular Genetic Testing Fraud?
Cardiovascular genetic testing fraud occurs when Medicare is billed for a cardio type of test or
screening that was not medically necessary and/or was not ordered by a beneficiary’s treating
physician.

What are Examples of Cardiovascular Genetic Testing Fraud?
Here are several ways cardiovascular genetic testing is advertised:
* Cardio/cardiac genetic screening/test                * Cardiovascular genetic screening/test
* Comprehensive cardiovascular panel                * Comprehensive cardiomyopathy NSG
* Cardiovascular disease genetic kit                    * Hereditary cardiovascular profile
• A company offering you “free” or “at no cost to you” testing without a treating physician’s order and
then billing Medicare.
• A company using “telemedicine” to offer testing to you over the phone and arranging for an
unrelated physician or “teledoc” to order the tests.
• Billing Medicare (usually thousands of dollars) for a broad range of cardiac genetic tests that you did
not request or possibly even receive.
• A company calls you stating your doctor or cardiologist requested that you have the testing done
and they will send you a testing kit.

What Happens if Medicare Denies the Cardiovascular Genetic Test Claims?
You could be responsible for the entire cost of the test. The average is $9,000 to $11,000.

Medicare Billing Codes
There are numerous Current Procedural Terminology (CPT) codes that have been associated with
cardiovascular genetic testing complaints as noted by SMP. The codes are in the 81400 – 81500 CPT
series associated with Gene Analysis & Molecular Pathology. You can review your MSN for these codes.

When is Cardiovascular Genetic Testing Covered by Medicare?
• 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.”
• 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.”
• When a treating physician orders the test as a diagnostic service and uses the results to manage the
patient’s condition.

What Can You Do to Stop Cardiovascular Genetic Testing Fraud?
• Be sure your doctor has assessed your condition. Although Medicare covers many genetic tests to
detect heart disease, it is not a test to predict or screen for cardiovascular disease.
• Do not give out your personal information to someone calling claiming your cardiologist has
requested the testing.
• Do not give out your personal information or accept screening services from someone at a
community event, a local fair, a farmers’ market, a parking lot, or any other event.
• Always read your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB). The words
“gene analysis,” “molecular pathology,” or “laboratory” may indicate questionable genetic testing
has occurred.
• If you received a cardiovascular genetic testing kit or test that was not medically necessary, report
your concerns about billing errors or possible fraud and abuse to your local SMP.

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. SMPs and their trained volunteers help educate and empower Medicare beneficiaries in the
fight against health care fraud. Your SMP can help you with your questions, concerns, or complaints
about potential fraud and abuse issues. It also can provide information and educational presentations.

To contact the Wisconsin Senior Medicare Patrol call: 888-818-2611 or email: smp-wi@gwaar.org