Preparing Your Lab for the Next Round of Payer Audits: Emerging Issues with Out-of-Network Billing, Medical Necessity, and Other Payer Concerns

Preparing Your Lab for the Next Round of Payer
Audits: Emerging Issues with Out-of-Network Billing,
Medical Necessity, and Other Payer Concerns

Webinar – Tuesday, February 24, 2015

Order your LIVE recording of the event on a CD.

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Learn why government and private health plans are taking tougher
actions to ensure that clinical labs and pathology groups are complying
with laws, regulations, and managed care contract terms


Clinical labs and pathology groups are reporting greater scrutiny of lab test claims and more audit activity by payers. What is noteworthy about this development is that the increased attention is going into new areas of lab billing and collections, such as out-of-network billing.

Another area of heightened investigation by private health insurers and Medicare program officials is medical necessity. The list does not stop there, as some labs report that health insurers have begun to scrutinize payments made by labs to physicians for studies, registries, and similar activities. Further, some of these investigations have even gone so far as to assess the medical necessity of lab tests ordered by these physicians for patients enrolled in such studies and registries.

Increased payer audits and analyses on these and similar issues associated with laboratory claims and collections puts every lab organization at risk, particularly if they are caught by surprise when a payer or a Medicare Administrative Contractor wants to audit the lab or requests documentation to support the medical necessity of selected lab test claims.

To provide lab administrators and lab coding/billing/collections professionals with the latest intelligence and timely information about these new payer priorities, The Dark Report is offering a special webinar titled “Preparing Your Lab for the Next Round of Payer Audits: Emerging Issues with Out-of-Network Billing, Medical Necessity, And Other Payer Concerns.” The 90-minute webinar will take place on Tuesday, February 24, at 1 PM EST.

Register NOW

Order your LIVE recording of the event on a CD.


To give you both a national and a regional perspective on how different payers are challenging labs on such issues as of out-of-network billing, balance-billing of patients, and medical necessity of selected lab test claims, The Dark Report has arranged for Jane Pine Wood and Richard S. Cooper to lead the webinar. Each is an attorney with McDonald Hopkins of Cleveland, Ohio, and each provides professional services to labs in almost every region of the United States.

That fact is important to you. It means they have likely worked with your state’s Blue Cross company, for example, on behalf of one of their clients. It also means that they understand how different private health plans have different audit and compliance concerns for labs submitting test claims to them. Thus, you’ll learn about the important regional variations in how these audits, compliance checks, and claims challenges are being conducted.

Expect Wood and Cooper to also identify and discuss other new issues with laboratory claims and collections. For example, Palmetto’s draft LCD guidance on IHC and special stains, when implemented, will establish new guidelines that affect many lab organizations across the nation.

The focus of this webinar will be on the emergence of new payer efforts to more closely challenge, audit, and scrutinize lab test claims relating to such aspects as out-of-network billing, patient balance-billing, medical necessity, and lab-to-physician payments for studies, registries, and the like. However, there is likely to be time for robust discussion of associated issues, such as changes specified by the Protecting Access to Medicare Act of 2014 (PAMA) that require the Centers for Medicare and Medicaid Services (CMS) to handle lab test claims in different ways.

There is much happening in how Medicare program officials and private
health insurers are auditing labs, challenging claims, and looking into
medical necessity. During this exceptional webinar, you’ll learn:

  • Why out-of-network billing has become the subject of payer interest and attention
  • What labs should do to prepare for an audit of out-of-network claims
  • Key issues in how labs balance-bill patients and why health insurers now want to enforce contract provisions governing patient billing
  • How your lab should respond when a payer sends a letter and wants documentation that your lab is billing patients appropriately
  • Why the OIG’s June 25, 2014, fraud alert about laboratory payments to referring physicians caught the attention of private insurers and is triggering audits involving this type of activity
  • Why payers are now motivated to ask labs to document medical necessity for a growing proportion of lab test claims, and essential steps every lab should take to prepare for medical necessity audits
  • Understand why payers are now scrutinizing lab payments to physicians for studies, registries, and similar activities
  • Discussion and review of related issues, including Palmetto’s draft LCD on IHC and special stains


DATE: Tuesday, February 24, 2015

TIME: 1 PM EST; 12 Noon CST; 11 AM MST; 10 AM PST

PLACE: Your computer and/or speakerphone

COST: $195 per site (unlimited attendance per site) through 2/13/15, $245 thereafter

TO REGISTER: Click here or call 1-800-560-6363 toll-free
(ONLINE REGISTRATION closes at midnight the day before the webinar)

For one low price—just $195 (through 2/13/15; $245 thereafter), you and your entire team can take part in this fast-paced, insightful webinar. Best of all, you’ll be able to submit your own specific questions during the Q&A session following our speakers’ prepared remarks. This is high value for you and your lab’s unique needs!

Get the authoritative advice and the practical guidance you need,
with your attendance of this timely and affordable webinar


This heightened scrutiny is catching many labs off-guard and unprepared. As an attendee of this important session, you will come away with essential information, designed to be actionable by you. It is your opportunity to get the inside scoop on these new and impactful payer audits of labs, before auditors show up in your lab.

How to Register:
1.  Online
2. Call toll free: 800-560-6363.

Your registration includes:

  • A site license to attend the webinar (invite as many people as you can fit around your conference table at no extra charge)
  • A downloadable PowerPoint presentation from our speakers
  • A full transcript emailed to you soon after the conference
  • The opportunity to connect directly with the speakers during the audience Q&A session

Register Now! Or for more information, call us toll-free at 800-560-6363.



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She is a member of DxMA, ASM and AMP and was a Microbiology Supervisor before transitioning to the diagnostic industry.”