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The Sherpa's Plan: Criminal Acts for 200 Bucks. Enter the Nurse Geneticist!!

Posted Oct 07 2008 7:14pm

There is a storm coming. The way clinical genetics services are delivered in academic centers needs to change. Trying to make money through incident services could costs counselors and genetics departments everywhere.

Billing through an extender leverages the already busy clinician and helps us see many patients.

When a physician needs to bill for an extender they pick an NP or a PA. If they pick a CGC and never see the patient, bill for a clinical consult, and have someone forge their name, then they could be in a little bit of trouble. Especially with Medicare.....

Yet that is precisely what is happening in a majority of medical centers in the country. In my unscientific poll, 15 of the top 30 institutions who host cancer genetics clinics are doing this exact thing. I won't point fingers anywhere, but Friends....this is insurance fraud.

How is that so?

Well, according to the CPT code 99245, which 20 of the top 30 do code for andbill insurance formust include....


Outpatient Consultation: CPT Code 99245
Key Components (All 3 meet or exceed requirements)
E/M Comprehensive History
E/M Comprehensive Exam
E/M High Complexity Medical Decision
Problem Severity
E/M Moderate Severity Problem
E/M High Severity Problem
Physician Time: 80 minutes


When I asked several patients referred and seen at several cancer genetics clinics in New England, only 10% said they were seen by the medical director of the clinic. 20% think they were seen by a doctor, but upon review it was a very disappointing 12% that ever were seen by an MD. Yet, a quick review of their EOBs stated that they received a 99245......


That is called insurance fraud in many instances. I wonder what the insurers would say if this cat were outta the bag?

This all could be solved if:

1. The physician saw the patient and did the majority of the work

2. A physician extender who can perform a physical exam does the majority of the work

3. They don't bill insurance and take only fee for service

4. They don't bill for a 99245 and instead use the genetic counselingCPT code 96040with HCPCS S0265: Genetic counseling, under physician supervision, each 15 minutes


Why isn't this happening?Because in a recent AJHG review. ....

Average reimbursement for 96040 was $53.87.

In the small number of instances where multiple submissions of 96040 were made because of a prolonged GC visit, payment for each submission was the same. Mean reimbursement for other E&M services were:

99241-$67.79,

99242-$113.17,

99243-$146.25,

99244-$243.68,

99245-$249.38.....(Man, my attorney makes 200 USD more per hour and he doesn't do nearly as much for my health!)


Willing to commit Insurance Fraud for 200 bucks per case? A resounding Yes!

My Friends, this is a non-sustainable situation. As soon as some insurers get wind of this (Trust me they already have) you will find fines and lawsuits galore. But I have a solution, the answer.....Nurse Geneticists. You see, nurses can be billed as physician extenders, legally. In some states doing this for CGCs is allowed....but that may change, given Medicare's reluctance.


“Incident to” billing enables certain categories of non-physician health care providers to bill through a supervising physician. Medicare permits this type of billing for the following non-physician practitioners: Clinical Psychologists, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives, and Certified Registered Nurse Anesthetists. Genetic Counselors are not included most of the time.


Nurses can perform exams....and NPs can do this on their own. PAs can also bill through physicians. This enables you to bill at a sustainable rate for services.


How can you help us accelerate this movement? Call your insurer. Demand to be seen by a physician or physician extender if you were going to be billed for a 99245. How would you know? Check your EOB (explanation of benefits). My geneticist friends will be having strokes now. Why? They are too busy in the lab or writing grant proposals to see patients.

"Especially the "Bread and Butter" BRCAs that the counselors see" unquote. Personally, I find it insulting to counselors to talk that way. They deserve clinical counterparts to collaborate with them. They are not your workhorse!
Secondly, there are many patients out there who could use a good physical exam to enhance their cancer work up. Why isn't this getting done? Because Clinical Genetics Departments sit inside basic science departments and the focus is on discovery. Not clinical care....why? I think I just showed you the CPT reason why. 250 a patient? I charge 750 per visit just to stay afloat!

Why should you demand this service? It will put stress on the broken system. To repair that system, we must first rebuild the foundation.

TheGenetics Education Program for Nurses at Cincinatti Childrensis doing just that. Nurses are the foundation of great clinical care. Why shouldn't they be a part of Genomic Medicine?

From their site:

The Cincinnati Children's Hospital Medical Center's Genetics Program for Nursing Faculty (GPNF) was a multifaceted genetics educational program for nursing faculty. The GPNF was made possible through funding from the Ethical, Legal, and Social Implications Research Program of theNational Human Genome Research Instituteat the National Institutes of Health and theDivision of Nursing, Health Resources and Services Administration.
The GPNF highly acclaimed offerings consisted of:

Seven annual on-site Genetics Summer Institutes (GSIs)
Web-Based Genetics Institute (WBGI)
Participant follow-up, educational support, and networking opportunities
A two-day genetics update workshop offered every two years

Nurses have existed on the fringe in this field. I am certain their day is coming. ISONG does too.

What isISONG? The International Society of Nurses in Genetics. They are committed to working with genetic counselors. I think this is the right way to go. Unfortunately, many departments view one or the other as an extra cost. That is, until now. You see, if the departments can get away committing fraud, then they won't staff appropriately. If they don't have to staff appropriately, they never get the collaboration which is needed here. They are too short sighted to see......


The Sherpa Says:

Legal loopholes may let your department survive with this "billing scheme" for now. But it will change very soon and someone will get fined or punished. I hope your academic center is ready to truly support the clinical department. Because if they are not, then they will find a nice home atHelix Healthor at any number of free standing private practices...... that obey the law...

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