Medicare Compliance for Clinical Laboratories

Number of Credits

2.5 P.A.C.E.®




Course Keywords:

This course provides P.A.C.E.® credit only and is not for individuals that are eligible for CME credit (physicians, nurse practitioners, nurses). For CME credit, register for the course under the Laboratory Director CME Program category where the course is offered for CME 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 (Medical Laboratory Scientists, Medical Technologists and Technicians, other testing personnel, 

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 course has been approved for P.A.C.E.® credit. There are no prerequisites for this course.

  • 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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