Natera Panorama: The Test, the Code, and the Coverage Gap

Natera’s $11 million Panorama settlement in 2018 resolved allegations of improper prenatal test billing and code misrepresentation involving government health care programs. The whistleblowers’ complaint brought the billing decision inside the company into view: which code described the test, which code brought in reimbursement, and what happened when employees questioned the choice. For someone who knows how a genetic testing laboratory turns an order into a claim, that is familiar ground.

The Justice Department’s announcement identified a federal settlement and separate state Medicaid payments. The Natera Panorama settlement covered allegations about test coverage, coding and the patients tested. Taxpayers bore the cost of the alleged overbilling of programs serving military families and other beneficiaries.

What the Natera Panorama Settlement Covered

Panorama is Natera’s non-invasive prenatal test, with optional panels that screen for microdeletion syndromes. The United States alleged that Natera knowingly submitted false or fraudulent claims for genetic testing to TRICARE, the Federal Employees Health Benefits Program and Medicaid between January 1, 2013, and December 31, 2016.

The government’s account separated restrictions on particular testing from the allegation that Natera used a code that misrepresented what it had performed. It also identified a separate allegation about testing patients with low-risk pregnancies.

TRICARE’s Laboratory-Developed Test Window

The first TRICARE allegation covered dates of service from January 1, 2013, through March 4, 2015. The government contended that Natera improperly billed Panorama, including its optional microdeletion panels, when TRICARE did not reimburse for certain laboratory-developed tests.

When a Genetic Testing Lab Bills a Microdeletion Panel to TRICARE

In Natera’s case, the government alleged improper billing for non-invasive prenatal screening of certain microdeletion syndromes throughout the broader conduct period, when TRICARE did not reimburse for that screening.

The Allegation About Low-Risk Pregnancies

The government also alleged that, during the broader period, Natera billed TRICARE, the Federal Employees Health Benefits Program and Medicaid for Panorama, including optional microdeletion panels, for patients with low-risk pregnancies. Natera denied this allegation.

The clinical information accompanying an order matters here alongside the test performed and the code billed.

When a Genetic Assay Code Conceals Noncovered Prenatal Screening

The United States alleged that Natera used an improper code to misrepresent Panorama and microdeletion screening billed to TRICARE, the Federal Employees Health Benefits Program and Medicaid during the broader conduct period.

The whistleblowers’ complaint described the alleged coding choices more closely. It alleged that Natera billed DNA codes at as many as 72 units per test. It also alleged that the company continued billing Panorama under DNA/chromosome CPT code 88271.

The complaint describes a meeting in which a whistleblower questioned why Natera was not using the SNP-based code. Its account puts the alleged reason for the choice in the CEO’s own words:

The alleged choice was simple: use the code that paid. The exchange connects the claim to a business decision about reimbursement.

The complaint also alleged that billing and finance personnel raised concerns about the codes, including a finance executive’s concern that Natera was not using the most appropriate code. An employee who heard those discussions may understand a choice that looks routine in a payment file.

From Test Order to Paid Claim

The government’s 1998 clinical laboratory compliance guidance addressed that handoff directly. Its discussion of requisitions said the form should ensure that the ordering professional makes an independent medical-necessity decision for each test the laboratory will bill. With an optional panel, the individual selection matters as much as the test’s brand name.

The industry was discussing that connection well before the Panorama case. The 1997 Laboratory Medicine article Model Plan Helps Laboratories Fight Fraud described recommendations for requisitions that record the medical necessity of each test. It also described notices to ordering physicians explaining the components of laboratory profiles, the billing codes used for them and how the laboratory would bill Medicare.

The article’s Medicare discussion offers a useful way to read the Natera allegations: follow the selection of the test through to the description billed. The clinical order, the optional panel, the service performed and the code sent to the payer should tell a consistent story. In the government’s Panorama account, the alleged misrepresentation occurred at the billing end of that chain.

This is where people in different jobs can explain different parts of the same transaction. An ordering-office employee may know what the clinician selected. Laboratory personnel may know what testing was performed. A billing employee may know how those services became claim lines and why a particular code remained in use after questions arose.

The Federal Settlement and State Medicaid Payments

The Justice Department announced the resolution on March 8, 2018. Natera agreed to pay $10,635,616 to resolve the federal claims and an additional $756,183 to state Medicaid programs under separate agreements for similar conduct.

Two whistleblowers brought the qui tam case under the False Claims Act in the Western District of Kentucky.

Progenity’s Prenatal Testing Claims Show a Related Pattern

In the separate Progenity prenatal-testing case, the government’s complaint alleged that the company used CPT code 88271 to seek Medicaid and VA payments for services the code misrepresented. According to that complaint, the coding produced payments for nonreimbursable tests or higher payments than Progenity was entitled to receive.

The Progenity complaint also alleged inducements to the people sending in orders: excessive blood-draw fees, meals and happy hours, and routine waivers of patients’ coinsurance and deductibles. Progenity made extensive admissions about its conduct in its civil settlement.

The same billing code appears in both cases. Progenity’s referral allegations also reach back to how the orders arrived at the laboratory.

What People Inside the Laboratory Can Explain

The useful account connects the service to the claim and the billing decision. In the Natera complaint, employees allegedly questioned which code the company used, and the alleged response concerned reimbursement. That gives an insider’s knowledge of the decision a place alongside the billing data.

We examine those connections with you: what the order selected, which optional testing accompanied it, what the claim represented and what people inside the laboratory understood about the payer’s coverage. If you worked in billing or finance, you may know why a code stayed in use. If you worked with ordering practices, you may know how optional panels were selected and described. Together, those details can explain how a healthcare billing practice operated.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. Our work starts with what you know about the testing and the decisions behind its billing.

You Know Why That Code Was Used

If you saw a prenatal test billed under a code chosen to get it paid, speak to one of our whistleblower experts about the decision behind the claim. We work alongside you to build the case and bring in laboratory fraud whistleblower lawyers who understand genetic testing claims and payer coverage. From the first conversation through the pursuit of a recovery, we put your knowledge of the business at the center of the case.