1. How Unrequested Blood Tests Become Medicare Fraud Allegations
Additional tests may draw scrutiny when patients sought only COVID-19 screening or the claims lack clinical support.
Extra Panels Beyond COVID-19 Screening
COVID-19 screening consent does not authorize unrelated blood panels. Respiratory panels need clinical support; repeated orders or complaints alone do not prove fraud.
Who Directed Tests and Billing Entries
Physician requisitions, LIS changes, and staff instructions may show who selected tests or codes. Prefilled forms do not establish individualized authorization.
DOJ announced Joseph Rodriguez's October 6, 2026, conviction for healthcare fraud conspiracy and six healthcare fraud counts involving unwanted blood tests billed under a physician's name. It was not a kickback verdict; sentencing was pending.
2. Matching Patient Requests, Lab Orders, and Medicare Claims
Trace each disputed test from registration to billing, preserving original records.
| Record | Issue |
|---|---|
| Patient intake | Tests requested |
| Physician requisitions | Orders and clinical basis |
| LIS and specimen logs | Tests and changes |
| CPT/HCPCS codes | Services billed |
| Marketing contracts | Referrals and payments |
Patient intake
- IssueTests requested
Physician requisitions
- IssueOrders and clinical basis
LIS and specimen logs
- IssueTests and changes
CPT/HCPCS codes
- IssueServices billed
Marketing contracts
- IssueReferrals and payments
Billing Codes and LIS Audit Trails
Compare submitted codes with orders and LIS histories. Software defaults may explain repeated entries without establishing coverage. Access logs identify who changed them.
Medicare Ordering Exceptions during the Pandemic
42 CFR § 410.32 governs diagnostic orders, with temporary exceptions during the COVID-19 public health emergency.
From September 2, 2020, one otherwise covered COVID-19 diagnostic test and one each of specified influenza or related respiratory tests needed for a final COVID-19 diagnosis could be performed without a practitioner order. Other coverage rules still applied; unrelated blood panels were not authorized. Apply the rules effective on each service date. The emergency ended May 11, 2023.
3. When Laboratory Billing and Referral Payments Raise Federal Charges
Criminal fraud, false claims, and referral offenses have different elements.
Healthcare Fraud and False Claims Act Exposure
18 U.S.C. § 1347 addresses knowing and willful healthcare fraud; § 1349 addresses related attempts and conspiracies. The civil False Claims Act, 31 U.S.C. § 3729, also reaches deliberate ignorance and reckless disregard.
A July 2026 Magnolia Diagnostics civil settlement over respiratory panels did not determine liability. Related matters may warrant False Claims Act defense.
Anti-Kickback Statute and EKRA Referral Payments
The federal Anti-Kickback Statute (AKS), 42 U.S.C. § 1320a-7b(b), governs federal-program referral remuneration. EKRA, 18 U.S.C. § 220, can also cover commercially insured laboratory referrals.
EKRA's employee and contractor exception is unavailable for compensation varying with referrals, tests, or amounts billed or received. That alone does not prove a violation.
Section 220(d)(1) makes EKRA inapplicable to AKS-prohibited conduct; it does not legalize that conduct. Kickback investigations examine payment formulas, services, and intent.
4. After a Federal Records Demand or Investigator Interview
Distinguish a contractor audit from an FBI or HHS-OIG inquiry. Check deadlines and demands.
Preserve Historical Specimen and Billing Records
Preserve orders, LIS audit trails, specimen logs, claims, and messages. Do not backdate or overwrite records. Parallel proceedings may involve healthcare fraud defense.
Assess Executive and Marketer Involvement
Identify who directed tests, changed orders, or received complaints. Ownership alone does not prove criminal intent. Counsel can assess interview requests and conflicts between the laboratory and staff.
5. COVID Testing Fraud Faqs
Can Medicare investigate claims from 2020 or 2021?
Yes. Investigations can examine older claims, but charges and lawsuits face time limits. Many federal noncapital crimes carry a five-year period under 18 U.S.C. § 3282(a). Civil False Claims Act suits follow six years or a qualified three-year government-knowledge period, capped at ten years, whichever ends later, under 31 U.S.C. § 3731(b). Dates and tolling matter.
Can a marketing company face charges without submitting Medicare claims?
Potentially, if its conduct and intent satisfy a fraud or referral-payment offense. Review messages and payment records.
Can a signed physician requisition establish that added tests were properly ordered?
Not necessarily. Check actual physician authorization, altered orders, and medical necessity. A signature alone does not establish coverage.
13 Oct, 2026
