Wiki Bundling Labs-Medicare

[coderjr]

Employer is telling me to bundle labs into panels. For example: CBC, TSH, CMP bundled into general panel for commercial plans BUT when it's Medicare, I am to unbundle. What's more, we get "get paid" for creatinine so I am to unbundle a BMP to all individual tests so we can get paid for the creatinine.

Any advise on how to handle this? I know it's fraud but I can't get through to the manager.

 

[Wendyh50]

Ask for it in writing

Advise your manager that billing for reimbursement is illegal and does not mirror the servies rendered.
Then state if they want to do this make a written policy. Usually when asked for it in writing they do research and realize it will be their neck if an audit recoups it.

 

[clopez]

You also need to share this with your manager that Laboratory billing is one of the initiatives of the OIG and unbundling services is seen as fraud and abuse which could exclude the providers from Medicare. Are they willing to take that risk? Document everything to cover yourself.

[OIG Work Plan 2014 Laboratory tests—Billing characteristics and questionable billing
Billing and Payments. We will review billing characteristics for Part B clinical laboratory (lab) tests and identify questionable billing. Context—Medicare is the largest payer of clinical lab services in the Nation. Medicare’s payments for lab services in 2008 represented an increase of 92 percent over payments in 1998. In 2010, Medicare paid about $8.2 billion for lab tests, accounting for 3 percent of all Medicare Part B payments. Much of the growth in lab spending has resulted from the increased volume of ordered services. Part B covers most lab tests and pays 100 percent of allowable charges; Medicare beneficiaries do not pay copayments or deductibles for lab tests. Medicare should pay only for those lab tests that are ordered by a physician or qualified nonphysician practitioner who is treating a beneficiary. (42 CFR ? 410.32(a). (OEI; 03-11-00730; expected issue date: FY 2013; work in progress)