Fear of an OIG audit is high. If threat of liability generates fear, lost reimbursements generate supreme frustration. They're losing money tracking diagnostic information and codes before, as well as after, running tests. Ga. Some facilities reportedly haven't filed any outpatient claims for lab work on Medicare or Medicaid patients for the better part of the last year for fear of being nabbed for improper filings, although that, too, is against the law. But without software tools or more employees well-versed in regulatory matters, labs have chosen to assume the losses rather than run the risk of fines and penalties.
Most products attack the problems on two fronts.
Front-end compliance checkers screen tests at the time of order entry for eligibility and medical necessity and generate ABNs when the tests aren't covered. Back-end checkers pick up claims failing medical necessity edit checks to ensure that false claims are not submitted. Nice work if you can do it. But John Spinosa isn't convinced that those solutions are the answer. These issues of compliance don't have anything to do with manufacturing and therefore are not really a lab system core competency.