 Series of Continuing Educational classes to follow a laboratory sample from pre-analytical through analytical to post analytical stages
 Define and identify a laboratory order, requisition, and required written authorization
 Understand CMS guidelines for medical necessity
 Define and indentify Medicare Fraud and Abuse
 Understand HIPAA, and Billing requirements
 Explain expectations for Compliance with Regulations

 CMS defines an order as a communication from the treating physician or practitioner requesting that a lab perform a diagnostic test for a beneficiary. Orders may be conveyed via:
 A written document signed by the treating physician/practitioner that is hand delivered, mailed or faxed to the treating facility
 Telephone call
 E-mail or other electronic means

 Chart notes
 Script Orders
 Electronic Orders
 Verbal Orders
 Client Encounter Forms
 Requisition

 CMS says a requisition is the actual paperwork, such as a form, that the physician provides the clinical diagnostic laboratory to identify the test or tests he or she wants performed.
 The requisition may contain patient information, billing information, specimen information, and test selection.
 CMS stated in the final rule that a requisition signed by a physician may serve as an order, to minimize confusion about signed orders vs. unsigned requisitions going forward.

 May provide the laboratory with information necessary to collect the correct specimen and perform testing, ie. Fasting
 Identifies the patient, the ordering physician and the tests requested
 Should include a diagnosis code(s) , a narrative diagnosis code(s)and how to bill
 May serve as an order when it includes the physician’s signature

 The laboratory must perform tests only at the written or electronic request of an authorized person. Oral requests fro laboratory tests are permitted only if the laboratory subsequently obtains written authorization for testing within 30 days.
 Records of test requisitions or test authorizations must be retained for a minimum of two years.
 The patient’s chart or medical record, if used as the test requisition must be retained for a minimum of two years and must be available to HHS upon request.

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The patient’s name or other unique identifier
The name and address or other suitable identifiers of the authorized person requesting the test and if appropriate, the individual responsible for utilizing the test results or the name and address of the laboratory submitting the specimen including as applicable a contact person to enable the reporting of imminent life threatening laboratory results or panic values
The test(s) to be performed
The date of specimen collection
For Pap smears, the patient's last menstrual period , age or date of birth, and indication of whether the patient had a previous abnormal report, treatment or biopsy
Any additional information relevant and necessary to a specific test to assure accurate and timely testing and reporting of results

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Medical necessity from a Medicare perspective is defined under Title XVIII of the Social Security Act, Section
1862(a)1(a):
No payment may be made under Part A or Part B of expenses incurred for items or service which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

 Frequency-limits the number of times a test can be ordered per year
 Medically Necessary-medically reasonable and necessary
 Investigational-tests that have not been approved by
CMS for reimbursement

 How to Bill should be selected by physician; patient, client, insurance, Medicare, or
Medicaid
 Insurance information should accompany the order to the laboratory to complete the billing process
 Advanced Beneficiary Notices should be properly executed prior to collection

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Health information is considered to be personally identifiable if it relates to a specifically identifiable individual; under 45 C.F.R. § 160.103, it generally includes the following, whether in electronic, paper, or oral format:
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Health care claims or health care encounter information
Health care payment and remittance advice;
Coordination of health care benefits;
Health care claim status;
Enrolment and disenrollment in a health plan;
Eligibility for a health plan;
Health plan premium payments;
Referral certifications and authorization;
First report of injury;
Health claims attachments;
Health care electronic funds transfers (EFT) and remittance advice; and
Other transactions that HHS may prescribe in future regulations.

 I am not a lawyer and am not providing you with legal guidance.
 It is always advisable to seek the advice of counsel when making decisions about areas of potential risk.

Medicare and Medicaid made an estimated $23.7 billion in improper payments in 2007. These included $10.8 billion for Medicare and $12.9 billion for Medicaid.
(U.S. Office of Management and Budget, 2008)

“Health Care Fraud is a serious offense. Those who believe that they can defraud the government and easily get away with it will find that they will be caught and prosecuted. The government both at the state and federal levels, have investigators to seek out fraud, when it occurs, and my office stands ready to prosecute those who try to take advantage of the system”
(United States Attorney George E. B. Holding)

 Fraud is intentional deception or misrepresentation that an individual makes, knowing or believing it to be false, and that the deception or misrepresentation could result in some unauthorized benefit to that individual or to some other person.

 Billing for services or supplies that weren't provided
 Altering claims to obtain higher payments
 Soliciting, offering or receiving a kickback, bribe or rebate (example: Paying for referral of clients)
 Provider completing Certificates of Medical
Necessity for patients not known to the provider
 Suppliers completing Certificates for the physician

Behaviors or practices that, although normally not considered fraudulent, are inconsistent with accepted sound medical, business, or fiscal practices, that may directly or indirectly, result in unnecessary costs to the program, improper payment, or payment for services that fail to meet professionally recognized standards of care or which are medically unnecessary.

 Excessive charges for services or supplies
 Claims for services that don't meet CMS medical necessity criteria
 Breach of the Medicare participation or assignment agreements
 Improper billing or coding practices

 In-Office Phlebotomist has an order for Glucose.
 The diagnosis flags for a diagnosis coder to cover medical necessity.
 IOP assigns DX code 250.00 after asking client office staff for code.
 IOP does not document information received from client office staff.

Which of the following is true?
 IOP committed Medicare Fraud.
 IOP committed Medicare Abuse.

 IOP committed Medicare Fraud.
 IOP committed Medicare Abuse.
IOP’s action (lack of documentation)was inconsistent with accepted, sound practice and resulted in cost to the Medicare system

 It’s late Friday afternoon and Susan, a billing analyst, is reviewing a list of claims exceptions.
She has a question about which test was performed on the patient. Her supervisor has left for the day. She asks a co-worker, Cathy, who suggests she wait and ask the supervisor on Monday. Susan wants to finish her work and get home so she lets the claim process with the more expensive test.

Which of the following is true?
 Susan committed Medicare Fraud.
 Susan committed Medicare Abuse.
 Susan and Cathy committed Medicare Fraud.
 Susan and Cathy committed Medicare Abuse.

Which of the following is true?
 Susan committed Medicare Fraud.
 Susan committed Medicare Abuse.
 Susan and Cathy committed Medicare Fraud.
 Susan and Cathy committed Medicare Abuse.
Susan’s action was inconsistent with accepted, sound practice and resulted in cost to the Medicare system.

The HIM department of Hope All is Well Hospital has a procedure that laboratory reports for respiratory cultures are to be reviewed for all patients with pneumonia. When a respiratory culture is positive, the procedure states that the coder should assign the code for a bacterial pneumonia.

Which of the following is true?
 This practice is acceptable
 The HIM department is committing abuse
 The HIM department is committing fraud

Which of the following is true?
 This practice is acceptable
 The HIM department is committing abuse
 The HIM department is committing fraud
Only the physician can determine a diagnosis. The hospital is knowingly over-coding (up-coding) claims to receive higher payment.

Good Care Hospital has a protocol that requires all new admissions to have an EKG, CXR, H&H, Chem-8 and U/A. The protocol was approved by the Medical
Executive Committee.
Should the Compliance Officer be concerned?
Why or Why not?

Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury. The physician is required to consider the patient’s signs, symptoms and complaints when ordering tests. A protocol that applies to all patient’s, regardless of condition, is not appropriate.

DHHS and DOJ
Health Care Fraud and Abuse Control Program
Annual Report for Fiscal Year 2010
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$2.5 billion in health care fraud judgments and settlements
$2.86 billion returned to Medicare Trust Fund (from above an prior years)
 opened 1,116 new criminal health care fraud investigations involving 2,095 potential defendants
 excluded 3,340 individuals and entities from participation

July 1, 2011: Medicare implements new screening technology to head-off fraud.
 Uses predictive modeling theory
 Monitors large numbers of claims for patterns
 Similar to systems used by credit card companies
 Looks at variables such as beneficiary, provider, type of service and assigns a risk score.
 Claims will be investigated prior to payment

 Be informed- understand Medicare eligibility, coverage, billing, and costs
 Be an educator- keep beneficiaries properly informed
 Be a responsible employer- review the
OIG Sanction list

 Implement a Compliance Program
 Be a Medicare Anti Fraud Team
Member- Contact the OIG hotline @ 1-
800-HHS-TIPS

 http://www.oig.hhs.gov
 http://www.cms.hhs.gov
 http://www.stopmedicarefraud.gov
 http://justcoding.com
 http://www.hcpro.com
 http://medtraining.com