Local coverage determination is a major guideline to prevent improper actions within reimbursement. Local coverage determination is “reimbursement and medical-necessity policies established by regional fiscal intermediaries.”(book, 312) Each state has different requirements and local medical review policies and local coverage determination will vary between the states. There is active local coverage determinations in the geographical location in which I am located. The Wisconsin Physicians Service Insurance Corporation (08202, MAC - Part B) is one of the local coverage determinations.
Under the Wisconsin physician service insurance corporation there are many sections, however, I picked the drug section. A general overview of the drug section entails many gridlines. Therefore, upon contractor request all documents must be available and all documentation must be maintained in the medical record. All pages must be legible and included the proper patient identification information. In addition, the record …show more content…
Where do we draw the line between care and profit when dealing with drug treatment? A physician can order more drugs to be tested that may not help the patient; however, it will raise the price of the treatment. This will create more profit for the physician. In addition to ordering more drugs, health care organizations can up code. Upcoding is “the fraudulent process of submitting codes for reimbursement that indicates more complex or higher-paying services than those that the patient actually received. “ The guidelines that were implemented are to prevent errors and fraud. However, frauds still occur, a health care lab company, Millennium Health, “agreed earlier this month to a $256 million False Claims Act settlement with the federal government.” The implementation of the Wisconsin physician’s service insurance corporation with the drug testing section will keep physicians honest and help prevent fraud and