OIG/Medical Necessity General Information
October 02, 2015
On behalf of Edward Thornborrow, MD, Director, UCSF Clinical Laboratories
TO: UCSF PHYSICIANS
FROM: UCSF Compliance Committee for Clinical Laboratories
RE: OFFICE OF INSPECTOR GENERAL, COMPLIANCE PLAN
As part of UCSF Compliance Committee for Clinical Laboratories' oversight plan for the federal Office of Inspector General (OIG), we are required to annually notify all physicians of the following policies, developed to reflect government guidance:
- Medicare national and local coverage determinations (NCD's & LCD's) exist for certain lab tests. Specific test information is in Medicare Bulletins distributed by the local carrier, Noridian HealthCare Solutions, LLC, or at http://labmed.ucsf.edu/labmanual/mftlng-mtzn/account/reqs/med-necess-reqs.html. The ordering physician is required to provide ICD-10 diagnosis codes that support the medical necessity of all tests ordered.
- Medicare and some other payers will not pay for screening tests if the patient displays no symptoms or evidence of disease and may not pay for tests that are not FDA approved or are experimental.
- Medi-Cal fees are equal to or lower than Medicare lab fees.
- All panels (organ and disease or custom) will be billed and paid only when all components are medically necessary.
- Reflex tests and reflex test criteria are listed in the lab manual at http://labmed.ucsf.edu/labmanual/mftlng-mtzn/test/info/2text2.html. For those tests for which non-mandatory reflex tests exist, reflex testing may be declined on the laboratory requisition.
- A current Medicare lab fee schedule with CPT (current protocol terminology) codes is available upon request from each Clinical Laboratory. Clinical Laboratories consultation is also available and accessed by calling the main line for each Lab.
Material contained in this yearly notification is current as of the date published and is subject to change without notice. The OIG believes that a physician who orders medically unnecessary tests and knowingly causes a false claim to be submitted may be subject to sanctions or remedies under criminal or administrative law.
In addition, we are required by Audit Services to communicate to you the means by which you may report incidences of fraud, abuse, waste or misconduct. Reporting can be done through the UCSF Whistleblower Coordinator at 502-2810 or by calling the Universitywide Whistleblower Hotline at (800) 403-4744.
If you have any questions regarding this memo, please contact Dr. Edward Thornborrow, Chairman of the UCSF Compliance Committee for Clinical Laboratories at (415) 476-7888.