Clinical Laboratory Services: Staying Abreast of Payer Policy

Author: Jennifer Bolen

There’s a large focus right now on drug testing and claims for clinical laboratory services related to drugs of abuse testing.  The payers are interested in this area because there’s been quite a significant amount of fraud and abuse identified through payer investigative techniques. So the payers have said, we’re going to examine these claims more closely.  We’re looking for documentation of medical necessity.  We’re looking for individualization of the testing to the person that has to either be responsible for the claim ultimately or has the contract with the payer in terms of just being insured by them or covered by them. So it will be helpful for physicians to sit down with practice administrators, take a look at the plans that they’re contracted with, what they say about coverage, about medical necessity for drug testing, and try to make sure that they’re doing it right in their practice.

Clinicians should support their prescribing decisions and their request for laboratory testing through accurate and complete medical record documentation.  Too often we see boilerplate used in electronic health records.  If you have your rationale documented and you have a proper test order, if you’ve looked at the test results, and you’ve incorporated them into your treatment plan, you likely will have medical necessity.  If you just try to check box your way through it or say drug test without anything more, you can have a claim denied, as well as run into trouble on the prescribing side.

Finally, clinicians need to be aware of changes to the clinical laboratory fee schedule as it relates to the coding of laboratory claims and coverage and reimbursement, or billing of those claims.  There’s a split process for that right now in 2015, on the commercial side and on the Medicare side. So paying attention to this will really help you make a proper application of the codes.  Be sure that your claims for reimbursement are true claims and not false claims and you’ll have a better opportunity of keeping the money in your pocket.

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