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As payers consider genetic-test coverage, specter of fraud looms large


Imagine there was a test that could personalize medical care. A quick blood draw or a swab of your cheek could customize medical treatment, offering new information on family illnesses, and providing physicians with a new tool for making or altering a critical diagnosis.

Actually, there's no need to imagine it. That test already exists. It's called genetic testing, and its newfound possibilities have generated significant excitement within the medical industry--understandably so. If genetic testing lives up to the hype, it could change the way doctors treat and manage serious illnesses, and prescribe medication.

The drawback: The tests can be expensive, ranging from less than $100 to more than $2,000, according to the National Genome Research Institute. Genetic testing is also relatively new, which means researchers still haven't completely uncovered which tests are reliable and how they should be integrated into medical care.

At least one rather important person believes genetic testing can live up to the hype. Last year, President Barack Obama announced a $215 million Precision Medicine Initiative that devoted significant resources toward genetic testing research. The bulk of that funding ($130 million) went to the National Institutes of Health to recruit more than one million volunteers, which Obama said will "propel our understanding of health and disease."

It all sounds pretty wonderful, but as Dr. Robert McDonough, senior director of clinical policy research and development at Aetna, told the New York Times last year, "We want to make sure the enthusiasm doesn't outpace the evidence."

McDonough sums up the thoughts of many payers. Even after Obama's announcement, insurers--both public and private--were reluctant to dive headlong into genetic testing. But within the last year, more insurers have jumped in. Most recently, Philadelphia-based Independence Blue Cross took genetic testing coverage up a notch becoming the first major insurer to cover whole-genome sequencing for a variety of cancers. Some wondered if the industry would face more pressure to cover a broad array of tests as a result.  

If more payers do decide to expand genetic testing coverage (and many probably will), fraud detection and prevention better be a priority. When it comes to testing, the words "new" and "expensive" might as well be a neon sign for fraudsters and nefarious laboratories looking to cash in.