Compliance Policy

Medical Necessity:
Only tests that are medically necessary for the diagnosis or treatment of a Medicare or Medicaid patient will be reimbursed. The Office of the Inspector General takes the position that when medically unnecessary tests are ordered which result in false claims to Medicare or Medicaid; the ordering physician may be subject to civil penalties under the False Claim Act.

The ordering physician/provider must submit diagnosis information, preferably an ICD-9 code, for each test ordered. The diagnosis must be consistent with the diagnosis recorded in the patient’s medical record on the date of service.

Medicare may not pay for non-FDA approved tests or those considered experimental.

Medicare generally does not pay for screening tests except for certain specifically approved procedures that have frequency limits.

Advance Beneficiary Notice (ABN):
If there is reason to believe that Medicare will not ay for a test, the patient should be informed of that fact.  The patient should sign a properly completed Advance Beneficiary Notice (ABN) form to indicate that they have been informed and are responsible for payment of the test if Medicare denies payment.