General information

Compliance

ACL is dedicated to fulfilling its legal duty to ensure that it is not submitting false or incorrect claims to government and private payors. ACL believes that it makes good business sense to incorporate an effective compliance program within the laboratory culture.

Advance Beneficiary Notice (ABN)

The purpose of the Advance Beneficiary Notice (ABN) is to give the patient advance notice that Medicare will probably not pay for the test(s) ordered and that they may be financially responsible for payment. It is the policy of ACL to obtain a signed Advance Beneficiary Notice (ABN) from the Medicare patient when laboratory tests ordered by their health care provider do not meet Medicare Guidelines for Coverage as outlined in the National and Local Medical Review Policies (LMRP) published by CMS and/or WPS. ACL will then bill the patient for the laboratory tests that are not covered by the Medicare program and/or any secondary insurance. A valid ABN will clearly identify the test(s) that are not covered by the Medicare program, will state the reason(s) for the Medicare denial and provide notification to the beneficiary that they assume financial responsibility for payment of these test(s). An example of the ABN Form may be found in the Appendix (section XI) of the Directory of Services. The ABN forms may be ordered through ACL.  Clients are responsible for determining when the ABN is required, obtaining a patient signature prior to specimen collection, and forwarding the top copy of the completed ABN along with the completed test requisition to ACL.

The Medicare National and Local Medical Review Policies are available upon request through the ACL Sales Department as resources to the client to assist them in the decision as to when the ABN is needed. For your convenience, you can click on the following link to save or print a copy of the National Coverage Decision Summary.

Medical Necessity

Medicare policy determines which types of services and conditions are "medically necessary". Medicare policy is not meant to question the health care provider's standard of practice, but rather provide guidelines as to when laboratory services will be paid by the Medicare program. Medicare will only pay for tests that meet Medicare Guidelines for Coverage and that are reasonable and necessary to treat or diagnose the patient. Medicare will not pay for approved tests deemed experimental or for research, and many screening tests. 

Only tests that meet Medicare Guidelines for Coverage may be submitted to Medicare for reimbursement. Individuals who knowingly cause a false claim to be submitted to Medicare may be subject to sanctions or remedies available under civil, criminal, and administrative law.

To avoid false claim submission, be sure to:

1. Order only those tests necessary for diagnosis or treatment. Note: each component of a panel must be necessary for the panel to qualify for Medicare reimbursement. 2. Provide a diagnosis, sign or symptom for each test ordered. 3. Document this information in the patient's medical record. 4. Obtain an ABN from the Medicare patient when tests do not meet medical necessity criteria.

Reflex Tests

Reflex Testing is additional testing approved by the Pathology staff and performed as a result of INITIAL test results which are used to further identify significant diagnostic information required for appropriate patient care.

All reflex test conditions will be identified and clients may choose to order the test without the reflex option. However, confirmation tests deemed medically necessary by the Pathology staff are always performed, unless the client specifically requests testing without confirmation. Additional fees will apply.