Why is Billing Compliance so important to the Department of Pathology?

According to the U.S. Office of Inspector General (OIG), laboratories play a special role in defending Medicare and other government health care programs against paying for medically unnecessary tests.  In exercising that defensive role, the lab is expected to take the offensive in clearly conveying and reiterating the government's medical necessity requirements for test reimbursement.  The Department of Pathology has established the following objectives to ensure our compliance:

• University Commitment Statement:

The University of Texas Southwestern Medical Center at Dallas and the Department of Pathology have a strong and abiding commitment to ensuring its affairs are conducted in accordance with applicable law. To underscore its commitment and to better assist all employees, including faculty physicians, in this area, UT Southwestern and the Department of Pathology have implemented a billing compliance program.

• University Standard of Conduct Statement:

It is the personal duty of each faculty physician and employee to conduct themselves in an ethical way and to provide billed medical services in compliance with all applicable rules, regulations and laws of the department, university and government agencies.

• Medicare's requirement for teaching physician presence in diagnostic process:

• The teaching physician must be present during the critical aspect of any service in which he or she involves a resident for which Medicare Part B payment is sought.
• Critical aspect of service: the point in the process at which diagnostic material has been prepared and is in process of review for a reportable diagnosis or interpretation.
• Medicare pays for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed or reviewed with a teaching physician. If the teaching physician’s signature is the only signature on the interpretation, Medicare assumes that he/she is indicating that he/she personally performed the interpretation. If a resident prepares and signs the interpretation, the teaching physician must indicate that he/she has personally reviewed the image and the resident’s interpretation and either agrees with it or edits the findings. Medicare does not pay for an interpretation if the teaching physician only countersigns the resident’s interpretation.
• Medicare's definition of medical necessity:

Services or supplies that: are proper and needed for the diagnosis, or treatment of a patient's medical condition; are provided for the diagnosis, direct care, and treatment of a patient's medical condition; meet the standards of good medical practice in the local area; and are not mainly for the convenience of a patient or doctor.  It is Medicare's program policy to reimburse for only medically necessary tests.

• Medicare's requirement for diagnosis to support medical necessity documentation:

A physician should only order tests that are medically necessary for the diagnosis and treatment of a medical condition, rather than for a screening purpose in absence of specific signs or symptoms.

• Medicare's Program Integrity statement:

This Medicare initiative established an overall approach to medical billing and collection activities.  It is a collection of individual government projects established to combat fraud and abuse in the Medicare System to achieve Medicare's goal of only paying for those services provided and needed.