Billing for non-covered laboratory services
may be considered Medicare fraud.
RulePro identifies unapproved test/diagnosis
combinations and provides an associated notice.
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Background
Rulings by the Centers for Medicare and Medicaid Services (CMS) now require
that certain limited coverage tests for Medicare patients
must be associated with particular
diagnoses. If a physician orders a limited coverage test and the
diagnosis is not linked to a predetermined list of covered conditions,
then Medicare will not approve payment for the test.
In addition, billing for non-covered laboratory services by provider organizations may be considered Medicare fraud and abuse.
The Need to Identify Test/Diagnosis Combinations
Provider organizations have three possible solutions, all
of which depend on the ability to identify unmatched tests and diagnoses:
- Perform only the test/diagnosis combinations approved by Medicare;
- Bill only the test/diagnosis that are approved by Medicare; or
- Identify non-covered tests and provide for printing of notices to patients before services are rendered.
The RulePro® Solution
RulePro® can be used in laboratory registration, outpatient registration,
physician offices, and/or patient financial services areas to:
- Enter and Organize the ever increasing number of payor/test/diagnosis combinations;
- Identify non-covered service situations for each patient based upon a few data elements that are entered into RulePro®; and
- Notify the patient of their need to accept financial responsibility
by providing for the printing of a notice for the patient's signature.
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RulePro® for Compliance