Rule of the Month: Automatically Tracking CLIA Requirements
Welcome back to the Rule of the Month! This month, we find out how athenahealth helps you keep track of CLIA requirements through our Rules Engine.
CLIA....what is that?
If you perform any lab services in your office or through a reference lab....CLIA is your business.
CLIA stands for Clinical Laboratory Improvement Amendments of 1988 (yes, it has been around for awhile).
What does CLIA do? The Centers for Medicare & Medicaid Services (CMS) regulates all laboratory testing (except research) performed on humans in the U.S. through CLIA. CLIA then assures that all CLIA laboratory tests are performed in appropriately-certified facilities and that the facility is specifically certified for the particular test as well. It’s a safety issue!
CLIA regulations are federal regulations and compliance with these regulations is very important. Sanctions can be taken against non-conforming laboratories. Sanctions can include both cancellation of Medicare payments and Civil Money Penalties.
Isn’t CLIA just for Medicare claims? Well, it used to be...and it is regulated by CMS. Today, however, CLIA regulations are also applied to some state Medicaids and even United Healthcare! Since it is a safety issue and one that protects the patient, we may see other payers adopting its standards in the future.
The tests that are considered CLIA laboratory tests may change each year. Practices need to know which tests are subject to CLIA edits and which tests are excluded from CLIA edits. Practices also need to know if their certification level supports the performance of certain tests.
Enter athenahealth!
athenahealth rules alert you to CLIA issues with your claims. There are many CLIA rules in our Rules Engine, including those that will tell you:
- If your CLIA number is in the right format.
- If your certification has expired.
- Where to put the CLIA number on the claim.
- About possible modifier use when the test performed is CLIA waived...or when the test is sent to an outside laboratory.
- Your level of certification and warn you if the test you are billing for is outside that level.
- If the CLIA number of your reference lab is needed on the claim.
Learn more about CLIA at http://www.cms.hhs.gov/clia.