CME: Medicare Compliance for Clinical Laboratories

Number of Credits

2.5 CME





This course provides CME credit and is only for individuals that are eligible for CME credit (physicians, nurse practitioners, nurses). All others should register for the course under the Laboratory Training category where the course is offered for
P.A.C.E. credit.

Course Details:

All health care providers, including laboratories, could potentially submit erroneous claims for Medicare reimbursement. These billing errors can trigger an investigation. The creation of a voluntary compliance program, using the guidelines provided by the Office of Inspector General (OIG), can assist health care institutions and laboratories to audit themselves, thereby preventing submission of erroneous claims and a possible fraud and abuse investigation.

This course is designed to train laboratory staff on the basic concepts of Medicare compliance. It is based on the OIG Compliance Program Guidance for Clinical Laboratories, and covers seven elements of a successful compliance program: risk areas, coding, ABNs, tests and panels, inducements, billing, and whistleblowers. It includes real-life case studies that highlight pertinent issues.

Intended Audience: The target audience for this course is all clinical laboratory professionals eligible for CME credit (Physician Laboratory Directors, Pathologists, nurses,

Learning Objectives

  • Define “voluntary compliance program,” discuss the elements that should be included, and explain why it is important for the laboratory to implement the program.
  • Identify the Medicare laws and regulations that are applicable to clinical laboratories.
  • Identify compliance problems and issues.
  • Explain each of these terms or processes that are related to Medicare reimbursements: Medical necessity; International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding; Advance Beneficiary Notice.
  • State the responsibilities of laboratory administration, management, laboratory employees, and the billing department that are related to Medicare compliance.

This CME activity has been designed to change learner competence and focuses on the American Board of Medical Specialties areas of patient care, practice-based learning and systems-based practice.

This Enduring Material activity, Laboratory Director Continuing Education Program, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Term of approval begins 08/01/2019. Term of approval is for one year from this date. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Approved for 2.5 AAFP Prescribed credits.

AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 Credit™ toward the AMA Physician’s Recognition Award.  When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category 1.

This course will take 2.5 hours to complete and there are no prerequisites. A credit certificate will be issued upon completion of the course evaluation and post-test with a score of 80% or better.

Release Date: 8/1/2017
Expiration Date: 8/1/2018

  • Voluntary Compliance Program
    • Introduction
    • Seven Elements of a Compliance Program
  • Laws and Regulations
  • Compliance Issues
    • Confidentiality
    • Billing
    • Inducements
    • Documentation
  • Processes and issues related to Medicare Reimbursement
    • Medical Necessity
    • ABNs
    • Coding
  • Test Ordering
    • Orders
    • Tests
  • Responsibilities for Medicare Compliance
    • Billing Department
  • Sales and Marketing
    • Equipment, contracts, and pricing
  • Whistleblowers
  • References
  • Graded Exam

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It is the policy of the AAFP and COLA Resources, Inc. that the faculty, authors, planners, and other persons who may influence content of this CME activity disclose all relevant financial relationships with commercial interests* in order to allow CME staff to identify and resolve any potential conflicts of interest. Faculty must also disclose any planned discussions of unlabeled/unapproved uses of drugs or devices during their presentation(s). For this educational activity all conflicts of interests have been resolved and detailed disclosures are listed below:

Activity Planner and Course Reviewer: Verlin K. Janzen, MD, FAAFP

No relevant financial relationships to disclose, No discussion of unlabeled/unapproved uses of drugs/devices during presentation.

* The ACCME defines a commercial interest as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients The ACCME does not consider providers of clinical service directly to patients to be commercial interests.

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