Faculty, Staff and Student Publications

Language

English

Publication Date

1-1-2025

Journal

Genetics in Medicine

DOI

10.1016/j.gim.2024.101248

PMID

39243182

Abstract

Purpose: Health care fraud comprises a sizable portion of United States health care expenditure and inflicts undue burden on payors, patients, and the health care system overall. The genetic testing industry is rapidly growing, which propagates opportunities for health care fraud. Although federal organizations have highlighted it as an issue, there is limited research exploring genetic testing fraud.

Methods: A retrospective review of federal websites, news articles, and a legal database resulted in 42 cases of fraud involving outpatient genetic testing published between February 2019 and December 2023. These cases were analyzed for themes via inductive conventional content analysis.

Results: Themes of fraudulent activity included submission of fraudulent claims, kickback or bribe payments, minimal or no contact with patients for whom testing was ordered, inappropriate billing and documentation practices, and further actions to conceal fraud. Repercussions imposed on defendants included monetary penalty, imprisonment, business restrictions, and seizure of property.

Conclusion: High rates of medically inappropriate testing in fraud cases highlight the value of genetics experts in ordering or reviewing claims for genetic testing. Examining fraudulent activity in genetic testing can help providers identify and report fraud and provide awareness of optimal health care allocation in the genetic testing industry.

Keywords

Humans, Genetic Testing, Fraud, United States, Retrospective Studies, Health Expenditures, Delivery of Health Care, Fraud, Genetic testing, Health care quality, Insurance claim review, Kickbacks, access, and evaluation

Published Open-Access

yes

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