Lab Pathology Alert — EAPG and DRG Payments
June 8, 2020The alert serves to notify lab pathology providers that Simply Healthcare Plans, Inc. and Clear Health Alliance (Simply) identified, via an internal claims audit, a claims payment error in their claims system related to the payment of lab pathology services covered under the hospital Enhanced Ambulatory Patient Group (EAPG) and Diagnosis Related Group (DRG) payment rates. They reviewed the use of all lab and pathology procedures performed in a facility as part of ongoing claim review activities and identified that Simply has been providing additional reimbursement for these services. Based on the Centers for Medicare & Medicaid Services (CMS) payment reimbursement guidelines, these services are not payable when the services were also reimbursed under the hospital EAPG and DRG payments. In compliance with the CMS coding guidelines, Simply is requiring all Medicaid and Florida Healthy Kids (FHK) lab pathology providers to adhere to the CMS coding guidelines, also adopted by the Agency for Health Care Administration for Medicaid. Simply will be adopting these guidelines for both Medicaid and FHK claims. Simply will cease providing additional reimbursement for pathology lab services already covered and reimbursed under the facility EAPG and DRG payments. Paid claims for their members were analyzed and overpayment was identified. Henceforth, notices will be going out to those lab pathology providers who appear to have received the additional reimbursement.