This webinar is presented by Elizabeth Sullivan, Member, McDonald Hopkins LLC and Courtney Tito, Attorney, McDonald Hopkins LLC.
Labs are under increasing scrutiny from government and commercial payors, and audit and recoupment actions are on the rise. Labs are charged with taking reasonable steps to ensure they are submitting claims for services that are reasonable and necessary and not for those that are not covered. Furthermore, a laboratory subject to an audit is considered to be in possession of credible information of an overpayment and must initiate a review as required by the Reverse False Claims Rule.
Medicare Audit and Appeals Process
- Medical records request
- Notice of payment suspension and/or pre-payment review
- Post payment review results
- Overpayment demand
- Request for redetermination
- Request for reconsideration with QIC
Commercial Payor Audit Process
- Determined by the individual payor
- Check online, provider manual, provider contracts for process
- Usually starts with a Medical Records Request and/or overpayment demand
- Can typically be resolved via settlement negotiations
60 Day Rule/Reverse False Claims
The entire process should be documented; correct the problem; identify and review policies/procedures involved in the action; identified and review potentially relevant documents; prepare a summary report.
What is EKRA?
Eliminating Kickbacks in Recovery Act of 2018 (EKRA) is an attempt to expand prohibited conduct that would be an AKS violation if a government payor were involved in any services paid for by any payor - applies to all payors.
This continuing education credit is intended for use by clinical laboratory professionals who are interested in learning about payor audits and how to prepare their lab for them.
Take the course and obtain CE credits
Attend this basic level webinars at no cost. Cardinal Health is approved as a provider of continuing education programs in the clinical laboratory sciences by the ASCLS P.A.C.E.® Program. This webinar is managed by Whitehat Communications and offer one P.A.C.E.® Continuing Education contact hour for up to six months after the live event.
One P.A.C.E.® credit is available upon completion of the course: Payor Audits – Preparing your Laboratory
P.A.C.E.® credits are widely recognized in the clinical laboratory profession and can be used to fulfill most continuing education requirements.
Disclaimer: The information in this presentation is provided for educational purposes only and is not legal advice. It is intended to highlight laws you are likely to encounter, but is not a comprehensive review. If you have questions or concerns about a particular instance or whether a law applies, you should consider contacting your attorney.