01-004 Specimen Validity Notification of Medical Review
Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Specimen Validity billed on dates of service from January 1, 2017 – December 31, 2017. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.
The Office of Inspector General (OIG), under report A-09-16-02034 dated February 2018, found that payments made to providers for specimen validity tests did not comply with Medicare billing requirements. The report outlined that providers did not follow existing Medicare guidance, and the CMS system edits were not adequate to prevent payment for specimen validity tests billed in combination with urine drug tests. The recommendations from the OIG included, (1) Direct the Medicare contractors to recover the $66.3 million in identified improper payments and (2) Strengthen its system edits to prevent improper payments for specimen validity tests, and instruct the Medicare contractors to educate providers on proper billing for specimen validity and urine drug tests, which could result in savings of an estimated $12.1 million over a five-year period.
Reason for Review
In response to the OIG report, the CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review
The SMRC will perform data analysis and medically review claims to determine if the specimen validity testing, when billed with urine drug tests, was medically reasonable and necessary. Medicare does not pay for separately billed specimen validity tests when billed with associated urine drug tests.
Noridian is reviewing claims for identified beneficiaries selected providers, and the review cannot be completed without additional information. The request for documentation will be sent to the provider that submitted the claim for the laboratory test. If the provider submitting the claim was an independent laboratory and, the documentation returned was insufficient, per the Internet Only Manual (IOM) Publication 100-08, Chapter 3, Section 184.108.40.206, the SMRC will solicit information from the ordering/referring provider.
Claim Sample Detail
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Access related project details below.
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.
- Treating physician order or documentation to support the intent to order
- Laboratory reports for all services billed
- Relevant and/or current records from physician’s/practitioner’s office, e.g., office notes, history and physical, labs, etc. as supporting documentation of medical necessity for service that was provided by laboratory provider, if applicable
- Medical documentation to support the treating physician used the results in the management of the beneficiary’s specific medical condition
- Advance Beneficiary Notice of Noncoverage (ABN), if applicable
- For illegible signature or unsigned medical record documentation, also submit a Signature Attestation Statement or Signature Log, if applicable
If the service is found to be rendered in an independent laboratory and sufficient documentation was not received, the items listed below will also be requested from the ordering physician in a subsequent request.
- Clinic/progress note(s) to support the medical necessity of the test(s) rendered on date of service
- How the results will be used in the treatment of the beneficiary
- ABN, if applicable
- Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits
- Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(a). Exclusion from Coverage and Medicare as a Secondary Payer
- Social Security Act (SSA) Title XVIII, Section 1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
- Social Security Act (SSA) Title XVIII, Section 1893 (b). Medicare Integrity Program
- Code of Federal Regulations Title 42, Section 410.32(a). Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
- CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 220.127.116.11 – Special Provisions for Lab Additional Documentation Requests
- CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 18.104.22.168 – No Response or Insufficient Response to Additional Documentation Requests
Last Updated Dec 27, 2018