Medicaid Information and Courses from MediaLab, Inc.

Element 5: Every employee must understand that the standards, policies and procedures associated with the compliance program must be adhered to at all times. Employee will be disciplined up to terminations for violations. Employee can be disciplined or terminated for failing to report a problem or suspect activity. All employees are screened prior to being hired for previous actions against them by any law enforcement or government agency regarding any health care prosecution or exclusion from the Medicare or Medicaid program. Adherence to the compliance program's policies and procedures will be a component of every employees annual evaluation and performance review.

The laboratory's couriers may not transport items except those related to the testing services offered by the laboratory. Couriers must follow all OSHA standards for the handling and transport of specimens. The laboratory is responsible for all tests it refers to other laboratories. Laboratory should not change CPT codes supplied by a reference laboratory without contacting the reference laboratory. The laboratory is responsible for all tests it bills to Medicare/Medicaid even if the test was performed by a reference laboratory.

Social Security Act: Medicare and Medicaid laws are in this act. Medicare rules and regulations come under this act. Antikickback laws: Provide criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit or receive money or favors for referrals of tests or services that will be paid for by the Medicare or Medicaid programs. False Claims Act: Provides criminal penalties for knowingly or willingly filing a false Medicare claim to a government program. Self Referral (Stark) laws and regulations: Identify financial relationships that have the potential to result in directed referral to one or both of the individuals or entities involved. Prohibit the referral of patients or tests between related entities unless certain conditions are met. Health Insurance Portability and Accountability Act (HIPAA) Prohibits health care providers and payers from improperly or inappropriately using a patient's confidential health information Requires health care providers to keep a patient's confidential information secure Provides for standardized electronic formats for all health care transactions

A laboratory that receives referrals from a nursing home or Skilled Nursing Facility (SNF) should have a written agreement with that facility: The Agreement should define billing and documentation responsibilities. The facility should be responsible for determining the payment status of its patients and is liable for submitting incorrect payment information to the laboratory. Fees should be consistent with other similar customers. A laboratory that provides services to a Home Health Agency treating Medicare/Medicaid beneficiaries should have a written agreement with that agency: The Agreement should define billing and documentation responsibilities. The Agreement should place the responsibility on the Home Health Agency to establish that all patients receiving laboratory services are "homebound" as defined by Medicare. Fees should be consistent with other similar customers.

The laboratory's couriers may not transport items except those related to the testing services offered by the laboratory. Couriers must follow all OSHA standards for the handling and transport of specimens. The laboratory is responsible for all tests it refers to other laboratories. Laboratory should not change CPT codes supplied by a reference laboratory without contacting the reference laboratory. The laboratory is responsible for all tests it bills to Medicare/Medicaid even if the test was performed by a reference laboratory.

On April 24, 2003, the Clinical Laboratory Improvement Amendments (CLIA) Final Rules went into effect.As of that date, each laboratory that introduces a nonwaived, unmodified, FDA-cleared or approved test system must do the following before reporting patient test results: Demonstrate that it can obtain performance specifications comparable to those established by the manufacturer for the following performance characteristics: Accuracy. Precision. Reportable range of test results for the test system. Verify that the manufacturer's reference intervals (normal values) are appropriate for the laboratory's patient population.