COMPLIANCE
POLICY
The mission of UP Health System – Marquette Laboratory is to provide fully integrated, comprehensive laboratory service to inpatients, outpatients, outreach clients and other community healthcare organizations in compliance with all applicable legal, regulatory and third party payment requirements.
The laboratory abides by all UPHSM developed policies to prevent any process or practice that may result in billing errors or activities that may be viewed as fraudulent.
Informing referring physicians and clients of our policy requirements assists us in providing the most efficient, quality service possible.
PHYSICIAN AND CLIENT RESPONSIBILITY
UP Health System – Marquette Reference Laboratory has a fiduciary obligation to remind physicians that when they order tests in which Medicare/Medicaid reimbursement will be sought, physicians should only order tests that are "medically necessary." This means that only tests that are required for the diagnosis or treatment of a patient can be ordered and reimbursed by Medicare/Medicaid. This government policy eliminates most testing for screening purposes only. Exceptions and Requirements are noted on following pages.
Medicare Patients Must Pay for Tests Ordered Outside Utilization Guidelines.
GUIDELINES FOR ORDERING LABORATORY TESTS
MEDICAL NECESSITY
Medicare is required by federal law to pay only for services it considers medically necessary to diagnose or treat an illness or injury or to improve the function of a malformed body member. As a result, Medicare often requires a specific diagnosis for certain laboratory tests before they will consider a test medically necessary.
Although physicians may order any tests they feel are necessary to diagnose and treat a patient appropriately, Medicare will only pay for those that meet the Medicare definition of medical necessity.
Therefore, all Medicare claims submitted by UP Health System – Marquette must include complete medical necessity documentation using the ICD-9CM coding system to be compliant and eligible for reimbursement of services provided.
LIMITED COVERAGE TESTS
Medicare has designated many commonly ordered tests (e.g. cholesterol, glucose, Prothrombin Time) as Limited Coverage Tests. The Centers for Medicare & Medicaid Services (CMS) have developed National Coverage Determinations (NCD) that govern which diagnoses are considered "reasonable and necessary". Local Medicare contractors have developed additional policies that govern which diagnoses are considered "reasonable and necessary" for their area. These policies are referred to as Limited Coverage Determinations (LCD). NCDs and LCDs have been developed based on review of pertinent medical literature, practice guidelines, peer review organizations' review criteria, outside consultants, medical practitioners and data on provider utilization.
ADVANCED BENEFICIARY NOTICE (ABN)
The intent and purpose of an ABN is to notify Medicare beneficiaries, in writing, that a test being ordered for them by their physician may not be paid for by Medicare. The beneficiary has the opportunity to make an informed decision about whether or not to have the test and be financially responsible should Medicare deny payment.
STANDING ORDER POLICY
When standing orders for laboratory testing are appropriate for an extended course of treatment, they may be established in the laboratory.
CONTACT US
UPHSM Laboratory has clinical consultants available to answer questions regarding appropriate testing and medical necessity. Please call 1-888-818-3879 for Client Services, 906-225-3707 for our Service Representative, or 906-225-7620 for a Billing Analyst.
