CMS Pub. 100-04, ch. 16, § 110.4

B3-2070.1.F

An important role of the A/B MAC (B) is as a communicant of necessary information to

independent clinical laboratories. Failure to inform independent laboratories of Medicare

regulations and claims processing procedures may have an adverse effect on prosecution

of laboratories suspected of fraudulent activities with respect to tests performed by, or

billed on behalf of, independent laboratories. United States Attorneys often must

prosecute under a handicap or may refuse to prosecute cases where there is no evidence

that a laboratory has been specifically informed of Medicare regulations and claims

processing procedures.

To assure that laboratories are aware of Medicare regulations and A/B MAC (B)’s policy,

notification must be sent to independent laboratories when any changes are made in

coverage policy or claims processing procedures. Additionally, to completely document

efforts to fully inform independent laboratories of Medicare policy and the laboratory’s

responsibilities, previously issued newsletters should be periodically re-issued to remind

laboratories of existing requirements.

Some items which should be discussed are the requirements to have the same charges for

Medicare and private patients, to document fully the medical necessity for collection of

specimens from a skilled nursing facility or a beneficiary’s home, and, in cases when a

laboratory service is referred from one independent laboratory to another independent

laboratory, to identify the laboratory actually performing the test.

Additionally, when A/B MAC (B) professional relations representatives make personal

contacts with particular laboratories, they should prepare and retain reports of contact

indicating dates, persons present, and issues discussed.