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Chapter 39 : Reimbursement Compliance

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Abstract:

In laboratory medicine, program integrity includes elements that ensure both accurate billing by the laboratory and accurate payment by the payor. Improper payments can be categorized as errors, waste, abuse, or fraud. While abuse can be considered as “bending the rules,” fraud is distinguished on the basis of intent and generally results from improper billing practices. The chapter discusses specific examples of the most common forms of reimbursement fraud and abuse found in the public and private sectors. Several entities are involved in ensuring program integrity for the CMS healthcare programs. While much of the focus has been on laboratory provider error in the claim submission process, contractors or third party insurers paying claims also have an absolute obligation to develop effective medical review processes. While payors have an obligation to “pay it right,” laboratory providers obviously have an obligation to “do it right” in the first place. The chapter defines seven key elements that the Office of Inspector General (OIG) compliance guidance specifies for a sound compliance program. The areas that commonly require compliance policy development may be divided into five main general areas of concern: coding and billing issues, medical-necessity issues, record retention, marketing practices, and compliance with OIG and CMS compliance issuances. All laboratories should have in place a comprehensive compliance program, with its key provisions and requirements in effect at all times with a zero-tolerance approach.

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Reimbursement Compliance, p 670-684. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch39

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Figures

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Figure 39.1

Program integrity activities focus on prevention and detection of improper payments resulting from a spectrum of related coding and billing activities (adapted from http://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/downloads/cpiinitiatives.pdf). doi:10.1128/9781555817282.ch39.f1

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Reimbursement Compliance, p 670-684. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch39
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References

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1.American Medical Association. 2012. Principles of CPT Coding. AMA Press, Chicago, IL.
2. Beatty, M. F. 1999. A survey measuring the degree of model compliance plan for clinical laboratories implementation in small/rural hospital laboratories. Clin. Lab. Manag. Rev. 13:8186. [PubMed]
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Tables

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Table 39.1

Government payor program integrity activities

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Reimbursement Compliance, p 670-684. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch39
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Table 39.2

Summary of areas requiring compliance policies

EOMBs, explanations of medical benefits; OSHA, Occupational Safety and Health Administration.

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Reimbursement Compliance, p 670-684. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch39
Generic image for table
Table 39.3

Examples of reflex test procedures

HPV, human papillomavirus; RT-PCR, reverse transcriptase PCR; HCV, hepatitis C virus; DAT, direct antihuman globulin test.

Citation: Baselski V, Weissfeld A, Sorrell F. 2014. Reimbursement Compliance, p 670-684. In Garcia L (ed), Clinical Laboratory Management, Second Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817282.ch39

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