Clinical Laboratories and Payer Scrutiny: Increased Audits, Recoupment Actions, Litigation

Description

Laboratories are under more regulatory and payer scrutiny than in the past. The OIG has called for clinical laboratories to take reasonable steps to ensure they are not submitting claims for services that are not covered, reasonable, and necessary. When clinical labs are unable to demonstrate medical justification or provide documentation during claim audits, payers seek recoupment from the clinical labs.

Receiving payment for lab claims is a challenge for clinical laboratories and pathology groups, especially in light of onerous requirements by health insurers that are causing the rejection of more and more lab test claims. Even if claims are resubmitted and paid, labs struggle financially. Medicare is scrutinizing lab test bills to make sure the government is not overpaying laboratories.

More and more hospitals use third-party labs but as a result of limited contracts, labs are billing under hospital payer contracts. These arrangements are eliciting increased scrutiny from both government and private payers. Labs must carefully navigate federal and state regulations to ensure compliance.

Listen as our authoritative panel examines compliance considerations for clinical laboratories. The panel will review the Stark Law framework, Anti-Kickback Statute, and related exceptions and safe harbors that apply to laboratory testing. The panel will focus on developments in compliance requirements for client account billing for laboratory testing. The panel will also identify risks and issues commonly associated with payer audits and share thoughts on how clinical labs can prepare for payer audits.