The OIG Compliance Program Guidance for Clinical Laboratories, Section II (F), states, "An ongoing evaluation process involving thorough monitoring and regular reporting to the clinical laboratory's corporate officers are critical to a successful compliance program."
Laboratory organizations that engage Verdem Health to perform an annual or periodic OIG compliance audit assessment designed to measure effectiveness are able to clearly demonstrate continual improvement, which is the key in proving "effectiveness". The objectives of this assessment are to (1) identify any OIG compliance deficiencies or areas requiring improvement, (2) provide recommendations to improve compliance, and (3) measure the level of compliance of each regulated practice reviewed.
Verdem Health has developed a unique process that measures (scores) the level of compliance of over 165 different high risk issues based on regulatory citing. Our approach involves interviews with selected staff, a review of selected policies and procedures, an evaluation of selected practices, and the analysis of selected data to identify any high-risk laboratory related practices.
Verdem Health's compliance audit assessment findings are presented in a detailed report which is broken down into major business management sections (e.g., Sales & Marketing, Patient Registration Practices, Laboratory Test Coding Practices, Billing Financial Management Practices, and others.) with clear "corrective actions" indicated where applicable.
Additionally, Verdem Health has developed a uniquely designed "Score Card" tool that summarizes the score of every risk issue evaluated compared to previous audit assessments performed. With Verdem Health's "Score Card" tool, organizational leaders are able to easily see and understand the impact of the changes that have been implemented and what needs to be done to ensure continual improvement.
Many hospitals and independent laboratories routinely bill incorrectly for services rendered, which may be in violation of False Claims statutes, or suffer large revenue losses due to poor billing practices.
Verdem Health's Medicare Part B claims review is a cooperative interactive process designed to determine if the organization's clinical laboratory test ordering, registration, medical necessity checking, result reporting, coding, and billing practices are in compliance and result in full collections.
Verdem Health's approach exposes the strengths and weakness of the current process flow steps (i.e., requisition design, registration test order entry, medical necessity checking, result reporting and billing process) that play a role in billing Medicare for laboratory services.
Through Verdem Health's cooperative interactive approach, organizations can easily identify areas requiring corrective action improvement. Additionally, having the key process flow department leaders involved in the review process gives them firsthand knowledge of the critical steps and issues involved in ensuing accurate billing and rapid collections.
Correct CPT coding is the responsibility of the provider of diagnostic services. The OIG Compliance Program Guidance for Clinical Laboratories states, "Laboratory compliance policies should ensure that the CPT or HCPCS code that is used to bill accurately describes the service that was ordered and performed. To ensure code accuracy, laboratories should require that individuals with technical expertise in laboratory testing review the appropriateness of the codes before the claims are submitted."
Verdem Health's laboratory chargemaster review is designed to ensure that all active billable tests listed in each Laboratory Information System (LIS) are properly mapped to the correct CPT or HCPCS code line-items in the billing chargemaster. This review also includes a test utilization and rational pricing analysis and will be performed in cooperation with knowledgeable laboratory management and staff.
Developments in the field of molecular diagnostics is exploding, giving laboratories incredible tools that enable more sensitive diagnosis of infectious diseases and the ability to quantify a number of factors for individual cancers that can aid in selecting the right therapy or drug for the patient.
Molecular diagnostic codes are scattered throughout the laboratory and pathology section of the AMA CPT listing. Unique and complex coding rules apply to molecular diagnostic procedures. As is always the case, the most precise code must be selected, which means that when an analyte has a specific CPT code, that code must be used rather than one of the less specific method code(s).
Verdem Health's approach to molecular diagnostic coding is two-fold:
- Determine if the CPT code being billed accurately reflects the test being performed in each procedure and
- Train selected individuals in the organization to perform accurate molecular diagnostic test coding for new and revised tests in the future.
Through this experience the organization can be confident in the CPT codes they use to bill for molecular diagnostic tests and develop an understanding of how to identify the CPT coding impact of future changes.
Many hospital histology laboratories, independent laboratories, and pathology practices struggle with accurate and consistent coding of surgical pathology and cytology diagnostic services. As a result, many unknowingly are either under- or over-billing for the services provided. Under-billing can result in a serious financial loss, while over billing may be considered a false claim violation that carries heavy personal and organizational penalties that can threaten the future of the organization and individual professional careers.
Verdem Health's surgical pathology and cytology coding auditing, monitoring and advisory services are designed to:
- Determine if the organizations CPT/HCPCS and ICD-10 diagnostic coding practices are consistent with accepted AMA and CAP coding conventions and
- Train the pathologists and histology staff to accurately code all types of surgical pathology and cytology cases.
Additionally, Verdem Health has developed an extensive Surgical Pathology & Cytology Coding Guide to aid laboratories and pathology professionals in ensuring accurate and consistent diagnostic coding.
Laboratory healthcare providers operate in a complex environment, so firms providing revenue cycle services must have strong people and process management skills, plus an in-depth knowledge regarding compliance issues, billing regulations, productivity and staffing benchmarks, information systems, project management, and key performance indicators.
Verdem Health believes that having a sound laboratory billing financial management system and a carefully managed billing and collection process is critical to growing a successful clinical laboratory and or pathology business.
Verdem Health has provided interim management services and assisted numerous laboratory clients to improve their revenue cycle processes, reduce denials and bad debt, and improve cash flow and net revenue.
Our clients include entities in financial distress who find themselves in a turnaround situation, entities on solid financial ground who want to improve their customer service image, as well as their financial standing, and entities who are already high performers that desire to achieve best practice status. We are dedicated to serving laboratory providers and work exclusively in the laboratory industry.