CLC Laboratory Financial Management & Reimbursement 2 — Questions and Answers
Question 1: The Anti-Kickback Statute (AKS) in the context of laboratory services prohibits:
- Laboratories from performing tests outside their CLIA scope
- Offering or receiving anything of value to induce test referrals for federal program patients (Correct answer)
- Physicians from ordering redundant laboratory tests
- Laboratories from billing patients directly for Medicare-covered tests
Correct answer: Offering or receiving anything of value to induce test referrals for federal program patients
The AKS makes it a criminal offense to offer, pay, solicit, or receive remuneration to induce referrals of items or services covered by federal healthcare programs, including laboratory tests.
Question 2: The Stark Law (Physician Self-Referral Law) primarily restricts:
- Physicians from ordering tests without documented medical necessity
- Physicians with financial relationships from referring patients for designated health services, including laboratory services (Correct answer)
- Laboratories from accepting referrals from non-participating physicians
- Hospital-based laboratories from billing independently of the hospital
Correct answer: Physicians with financial relationships from referring patients for designated health services, including laboratory services
The Stark Law prohibits physicians who have a financial relationship with an entity from referring Medicare/Medicaid patients to that entity for designated health services including clinical laboratory services, unless a specific exception applies.
Question 3: Qui tam provisions of the False Claims Act allow:
- Medicare to audit laboratory claims retroactively for up to 10 years
- Private individuals to file lawsuits on behalf of the government and share in financial recoveries (Correct answer)
- Laboratories to appeal denied claims directly to federal district court
- Physicians to self-report billing errors in exchange for immunity
Correct answer: Private individuals to file lawsuits on behalf of the government and share in financial recoveries
Qui tam provisions empower private individuals (relators/whistleblowers) to file suit on the government's behalf and receive 15–30% of any recovered funds.
Question 4: The OIG Work Plan is a valuable compliance tool for laboratory consultants primarily because it:
- Provides the current Medicare fee schedule for all laboratory CPT codes
- Identifies areas the Office of Inspector General is actively scrutinizing for fraud and abuse (Correct answer)
- Lists all CLIA-certified laboratories in the United States
- Establishes annual staffing benchmarks for clinical laboratories
Correct answer: Identifies areas the Office of Inspector General is actively scrutinizing for fraud and abuse
The OIG Work Plan describes planned and ongoing reviews, audits, and investigations, alerting laboratories to the compliance risk areas receiving current government attention.
Question 5: 'Upcoding' in laboratory billing is defined as:
- Updating CPT codes to reflect current AMA revisions
- Billing for a higher-complexity or more expensive test than what was actually performed (Correct answer)
- Adding diagnosis codes to support medical necessity after the fact
- Submitting duplicate claims to two different payers simultaneously
Correct answer: Billing for a higher-complexity or more expensive test than what was actually performed
Upcoding involves intentionally billing a service at a higher code level than performed, resulting in higher reimbursement and constituting healthcare fraud.
Question 6: An effective laboratory compliance program, as outlined in OIG guidance, must include:
- Annual external CLIA inspections and proficiency testing enrollment
- Written policies, a compliance officer, training, internal auditing, and a confidential reporting mechanism (Correct answer)
- Only HIPAA privacy training and billing documentation requirements
- Monthly claims submission reports filed directly with CMS
Correct answer: Written policies, a compliance officer, training, internal auditing, and a confidential reporting mechanism
The OIG's seven elements of an effective compliance program include written standards, a compliance officer, training, communication channels, auditing, discipline enforcement, and corrective action procedures.
Question 7: A prospective billing edit check system in a laboratory compliance program is designed to:
- Recover overpayments identified during post-payment audits
- Identify and correct coding or coverage errors before claims are submitted to payers (Correct answer)
- Monitor physician ordering patterns for potential over-utilization
- Audit CLIA test performance records against billing records
Correct answer: Identify and correct coding or coverage errors before claims are submitted to payers
Prospective edit checks catch errors prior to claim submission, preventing improper payments and reducing exposure to audits and recoupment demands.
CLC Laboratory Financial Management & Reimbursement 2
The Anti-Kickback Statute (AKS) in the context of laboratory services prohibits: