OIG Identifies Questionable Billing for Laboratory Services

More than 20 percent of all claims for Medicare Part B clinical laboratory services submitted in 2010 are tied to “questionable billing patterns,” according to a July report from the Health and Human Services Office of Inspector General (OIG). The OIG identified 13 measures describing questionable billing. Any laboratory that exceeds the established thresholds for five or more of the 13 measures may warrant further scrutiny, said the OIG in the report. The study included 94,609 individual laboratories and 145.6 million claims. Of these, 1,032 laboratories exceeded thresholds for at least five of the measures. These laboratories were paid more than $1 billion for services in 2010. Measures include high averages of allowed amounts per claim, claims per beneficiary, amount per beneficiary, the number of claims per ordering physician, duplicate billing, and allowed amounts per ordering physician. Other measures are high percentage of claims that include compromised or invalid ordering physician identification numbers, compromised laboratory provider number, and compromised beneficiary identification numbers. The OIG recommends that CMS review the labs that are identified as exhibiting questionable billing and take appropriate action, which could include recouping overpayments if any are found.