Medicare Compliance & Reimbursement

Laboratory claims have long been a chief target of fraud enforcement agencies, and the scrutiny isn't letting up. Federal prosecutors in Philadelphia April 22 filed a False Claims Act suit against Abington Memorial Hospital, charging the facility with illegally unbundling Medicare lab claims - even after the Pennsylvania health department warned it of problems with its lab billing on the Medicaid side. According to U.S. Attorney Patrick Meehan, Abington submitted more than 70,000 false claims to Medicare between 1991 and 1999. Specifically, the feds maintain that the hospital: unbundled blood chemistry tests;
double-billed, unbundled or upcoded certain hematology tests (HCPCS codes 85021-85025, 85027 and 85595);
unbundled and double-billed urinalysis tests (HCPCS codes 81000-81003, 81005 and 81015); and
billed for low-density lipoprotein cholesterol measurements that weren't performed. The complaint maintains that the troubling findings of a 1993 Medicaid audit "should have placed Abington on notice that the same or similar failings were present in its billings for outpatient laboratory services for Medicare." Despite that notice, the feds contend, the hospital continued to bill Medicare improperly for lab tests. Abington President Richard Jones Jr. says that while the hospital did receive some inadvertent overpayments, it never intended to defraud the government, according to news reports. He notes that the facility has offered to refund the overpayments. Lesson Learned: Laboratories need to make sure they have adequate compliance measures in place, particularly for blood chemistry panels and LDL cholesterol, urinalysis and hematology tests.