Navigating Laboratory Schemes: Trends, Red Flags, and Best Practices

Understanding laboratory schemes is essential to recognizing trends, identifying red flags, and adopting best practices to safeguard against fraud, waste, and abuse. Here’s an overview of what you need to know:

??Does the Lab Exist?

Before delving into specifics, always verify the legitimacy of the lab. This is the first step in preventing fraudulent activities.

??Know Your Plan, Know Your Policy

Understanding your insurance plan and its policies is crucial. Familiarize yourself with the guidelines to better navigate and identify potential fraud.

??Common Schemes and Lab Trends

1. Unbundling Services from a Panel

- This involves separating a comprehensive panel of tests into individual tests billed separately, often resulting in higher overall charges.

2. Split Billing Over Multiple Claims

- Watch out for instances where services are billed across multiple claims to avoid detection of fraudulent activities.

3. Modifier -59 on Every Service

- The frequent use of Modifier -59, which is meant to indicate a distinct procedural service, can be a red flag for unbundling or other improper billing practices.

4. Pass-Through Billing

- This occurs when a provider bills for services that were actually performed by another provider, often without the required qualifications or proper documentation.

5. Billing Services Not Rendered or Unqualified to Perform

- Be vigilant for claims that include services not actually performed or performed by individuals lacking the necessary qualifications.

??Specific Areas of Concern

1. Urine Drug Testing

- Presumptive Testing (80305-80307): These codes cover basic tests that determine the presence or absence of drugs.

- Definitive Testing (G0480-G0483): These codes measure the specific amount of drugs in the system.

2. Genetic Testing and Genetic Sequencing

- Commonly Abused Code: Unlisted molecular pathology (81479) is often exploited.

- Unbundling Genetic Tests: Separating tests from a panel to increase reimbursement.

- Code Ranges: Keep an eye on codes 81105-81599 and 0001U-0241U for molecular pathology services.

??Best Practices for Identifying and Managing Lab Schemes

- Regularly Review Data: Stay on top of your data to spot anomalies and trends that could indicate fraudulent activities.

- Conduct Medical Reviews: Ensure thorough reviews of medical records to verify the necessity and accuracy of billed services.

- On-Site Visits: Periodic inspections of labs can help verify their existence and the legitimacy of their operations.

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?? Watch the Webinar Recording

If you missed our live webinar, "Navigating Laboratory Schemes: Trends, Red Flags, and Best Practices," you can now access the recording to gain in-depth insights into these crucial topics. Our expert presenters, Lera Champagne-Andriani and Mandi Berg , discuss key policies, top schemes affecting the laboratory specialty, and share valuable tips on working these cases, including red flags in the data, medical reviews, and on-site visits. Additionally, the webinar covers GLP-1 drugs (e.g., Ozempic), common schemes, and data mining techniques to capture fraud, waste, and abuse.

Stay ahead in the fight against healthcare fraud.