Clinical Laboratories and Payer Scrutiny: Increased Audits, Recoupment Actions, Litigation
Course Details
- smart_display Format
On-Demand
- signal_cellular_alt Difficulty Level
Intermediate
- work Practice Area
Health
- event Date
Thursday, August 15, 2024
- schedule Time
1:00 p.m. ET./10:00 a.m. PT
- timer Program Length
90 minutes
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This 90-minute webinar is eligible in most states for 1.5 CLE credits.
This CLE course will guide healthcare counsel on compliance considerations for clinical laboratories. The panel will discuss how the Stark Law framework, Anti-Kickback Statute, and related exceptions and safe harbors apply to laboratory testing. The panel will also discuss developments in compliance requirements for client account billing for laboratory testing and identify risks and issues commonly associated with payer audits.
Ms. Sullivan chairs the firm’s National Healthcare Practice. She assists clinical laboratories, hospitals, physician specialty groups, surgery centers, pharmacies, and other healthcare providers on regulatory, licensing, compliance, reimbursement, contractual, and corporate matters. She provides support to entities during licensure and accreditation surveys and assists in navigating state professional licensure laws, CLIA standards and state laboratory laws, government and private payor reimbursement, fraud and abuse rules, state telehealth laws, HIPAA rules and regulations, and state and federal pharmacy regulation.
Ms. Tito counsels and represents clients in government and private payer audits and other payer disputes, and compliance false claims act investigations and related proceedings. She represents clients before the Department of Health and Human Services, Civil Remedies Division related to appeals, revocations or payment suspensions. She also counsels and represents clients in business and commercial litigation and litigation-related matters. Her practice focuses on litigation and dispute resolution in a broad array of cases including business torts, breaches of contract, lender liability, restrictive covenant disputes, and intellectual property disputes.
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.
- Compliance considerations for clinical laboratories
- Developments in compliance requirements for client account billing for laboratory testing
- Risks and issues commonly associated with payer audits
- Information on how clinical labs can be prepared for payer audits
The panel will review these and other key issues:
- How are more and tougher payer audits raising compliance challenges for clinical laboratories?
- What steps should clinical labs take to ensure compliance with requirements for client billing for testing?
- What risks and other issues are associated with payer audits?
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