decisionhealth Newsletters, Answer Books - 2009 Issue 3 (March)
Diagnostic Tests / Fraud Alerts / Independent clinical labs that appear to be paying kickbacks or incentives to physicians
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Article Overview
This article explains a fraud alert focused on a suspected kickback arrangement involving independent clinical laboratories and referring physicians in the context of Medicare diagnostic testing. It is aimed at compliance staff, auditors, coders, and physicians who need to understand the broad Medicare billing and anti-kickback concerns raised by this type of arrangement. The discussion covers the OIG investigation, general Medicare rules for diagnostic test billing, and the compliance red flags associated with a global billing pattern for Holter monitor services.
Why This Topic Matters
The article highlights a potential compliance risk affecting diagnostic testing arrangements and Medicare reimbursement. It matters to organizations that bill or refer for clinical laboratory and cardiac monitoring services because it describes a suspected scheme, the applicable legal framework, and a billing pattern that may warrant review.
What You Will Learn
- Why certain diagnostic test billing arrangements can raise fraud and abuse concerns
- How Medicare rules distinguish between technical and professional components in diagnostic testing
- What general compliance issues may arise when independent labs and referring physicians are involved
- What broad billing patterns may prompt closer review in a fraud alert context
Who Should Read This
- Medical coders
- Compliance officers
- Billing managers
- Physicians
- Clinical laboratory staff
- Auditors
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