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Chapter 37 : Reimbursement Compliance

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Reimbursement Compliance, Page 1 of 2

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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. This chapter describes what constitutes fraud and/or abuse and discusses specific examples of the most common forms of fraud and abuse found in the public and private sectors. It talks about a prepayment review and its relationship to reimbursement and describes some of the legal ramifications that might be associated with a post payment review. The chapter defines seven key elements within a sound compliance program and discusses some of the acceptable marketing practices, as well as some that may not be in compliance. Finally, the chapter provides several specific examples of potential laboratory fraud and abuse. Claim review processes will identify many unintentional errors, particularly those pertaining to inadequate documentation. Compliance has taken on a new meaning during the last few years as laboratories have been accused of and found guilty of fraud and abuse. Laboratories and laboratorians must comply with rules and regulations related to reimbursement. It is mandatory that laboratory personnel maintain a thorough understanding of coding and billing practices. All laboratories should have in place a comprehensive compliance program, with its key provisions and requirements in effect at all times.

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Reimbursement Compliance, p 592-602. 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.ch37

Key Concept Ranking

Hepatitis C virus
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Reverse Transcriptase PCR
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References

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Tables

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Table 37.1

Summary of areas requiring compliance policies

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

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Reimbursement Compliance, p 592-602. 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.ch37
Generic image for table
Table 37.2

Examples of reflex test procedures

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

Citation: Baselski V, Weissfeld A, Sorrell F. 2004. Reimbursement Compliance, p 592-602. 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.ch37

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