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UPL is dedicated to fulfilling its legal duty to ensure that it is not submitting false or incorrect claims to government and private payers. UPL believes that it makes good business sense to incorporate an effective compliance program within the laboratory culture.
Advance Beneficiary Notice:
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 UPL 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. UPL 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).
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.
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.
Unless otherwise specified, UPL will bill clients a global fee for Cytology and Surgical Pathology services. The global fee includes the technical processing charge as well as the professional pathology fees for reading, interpretation and diagnosis.