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Case Study

A billing clerk is entering billing demographics on requisitions as a part of the normal day's work. The department is under pressure to reduce accounts receivable, which means that the more clean claims that are filed, the better. This particular requisition is for a Medicare patient and has an LMRP test but does not have a diagnosis on it. The billing clerk remembers that just a few requisitions before this one she had a requisition from the same doctor that had this same test on it that did have a diagnosis that allowed the test to be billed. She thumbs back in the pile and finds the previous requisition, notes the code that was used, and adds it to the current requisition. This will help her meet the department goal of getting claims paid and reducing accounts receivable. Can she do this?

Correct Answer: She cannot do this because it is against the law to change diagnosis information on a requisition.
Discussion: An employee should never change, add or use previously received diagnosis information for the purpose of making a test billable for the Medicare program or for any other insurance or payer. This is a form of fraud and for each claim submitted as a result of this activity, the healthcare entity is liable for a false claim and would have to pay the government back up to three times the reimbursement for the test and up to $10,000 for each claim submitted. If the employee is caught doing this, even if the employee is ignorant of the law and any laboratory policy prohibiting it, the employee must be disciplined along with the employee's supervisor. Any employee who notices another employee doing this should correct the employee and report the incident to the department supervisor immediately.