Chapter 36 : Rules and Regulations in Reimbursement

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.