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Chapter 36 : Rules and Regulations in Reimbursement

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Abstract:

Beyond the basic logistical issues surrounding the battle for laboratory reimbursement are a number of issues which pertain to the rules of engagement. The chapter discusses the rules set forth by third-party payors that determine claim payment. Failure to complete all required data fields in a claim for laboratory services will result in a denial from a thirdparty payor. The chapter describes the term “medical necessity” and its relationship to reimbursement and certain special coverage conditions for which unique billing rules may apply. It is important to understand how your local medical review policies (LMRPs) are set, where the committee is located, and how to contact the committee members for claim denial clarifications. The chapter discusses the importance of claim compliance to reimbursement and national coverage determinations and the relationship between these determinations and local medical review policies. The importance of reviewing all claim denials cannot be overemphasized. A beneficiary receives a Medicare summary notice, which provides specific and standardized explanatory information that identifies the reason for the denial. Follow-up can include obtaining additional documentation, resubmitting the claim, initiating an appeal process, or billing an alternative party. The chapter concludes with a description on the most common reasons for reimbursement denial and what can be done to correct the problems.

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Rules and Regulations in Reimbursement, p 583-591. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch36

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References

/content/book/10.1128/9781555817695.chap36
1. Alwell, M. 2003. Stem revenue losses with effective CDM management. Healthc. Financ. Manag. 57:8488.
2. Carter, D. 2002. Optimizing revenue by reducing medical necessity claims denials. Healthc. Financ. Manag. 56:8894.
3. Cathey, R. 2003. 5 ways to reduce claims denials. Healthc. Financ. Manag. 57:4448.
4. Murray, M. E.,, and J. B. Henriques. 2003. Denials of reimbursement for hospital care. Manag. Care Interface 16:2227.
5. Parker, S.,, N. Davidson,, and R. Gagliano. 2002. Preventing and dealing with ESRD claim denials. Nephrol. News Issues 16:18-21, 2526.
6. Reed, R. L.II,, K. A. David,, G. M. Silver,, T. J. Esposito,, V. Tsitlik,, T. O’Hern,, and R. L. Gamelli. 2003. Reducing trauma payment denials with computerized collaborative billing. J. Trauma 55:762770.
7. Reiser, W. S.,, and B.O. Brunicardi. 2002. Assessing the impact of Medicare payment changes. Healthc. Financ. Manag. 56:6871.
8. Sutton, J. P.,, J. Stensland,, L. Zhao,, and M. Cheng. 2002. Achieving equity in Medicare disproportionate share payments to rural hospitals: an assessment of the financial impact of recent and proposed changes to the disproportionate share hospital payment formula. J. Rural Health 18:494502.
9. Wallack, S. S.,, and C. P. Tompkins. 2003. Realigning incentives in fee-for-service Medicare. Health Aff. (Millwood) 22:5970.

Tables

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Table 36.1

Major required elements for claims submission and subsequent reimbursement

CLIA, Clinical Laboratory Improvement Amendments.

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Rules and Regulations in Reimbursement, p 583-591. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch36
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Table 36.2

Procedure code edits

AMA, American Medical Association.

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Rules and Regulations in Reimbursement, p 583-591. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch36
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Table 36.3

NCDs

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Rules and Regulations in Reimbursement, p 583-591. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch36
Generic image for table
Table 36.4

Special coverage conditions

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Rules and Regulations in Reimbursement, p 583-591. In Garcia L, Baselski V, Burke M, Schwab D, Sewell D, Steele J, Weissfeld A, Wilkinson D, Winn W (ed), Clinical Laboratory Management. ASM Press, Washington, DC. doi: 10.1128/9781555817695.ch36

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