If a lab holds an out-of-network position, its business
opportunities may be more problematic. Labs may bill 100% of their charges
to an insurance company but, in order to remain competitive with in-network
participating labs, they may write-off any patient balance (accepting as
payment-in-full the amount from the insurance company). A lab may be liable,
however, for waiver of co-insurance, deductibles, or balance obligations.
This type of activity can raise issues under various fraud and abuse laws.
Audit Defense – Our firm has expertise representing laboratory clients in RAC, ZPIC, MAC, Medicare, Medicaid, and private payor audits. We also assist our clients when appealing claim denials through all levels of the appeals process. We have an expert understanding of the procedural, substantive, and strategic issues involved in Medicare audit defense appeals from the initial redetermination stage up to and including appeals in federal district court. We work with our clients to understand the substantive issues unique to each clinical laboratory or POL audit and to develop an effective and practical audit defense strategy, including drafting position papers and written submissions specifically tailored to each audit. We also have expertise in advising clients who have been placed on pre-payment review or payment suspension.