Medical Necessity Requirements: Office of Inspector General, Compliance Plan
Welcome to the UCSF OIG/Medical Necessity compliance page. As part of Clinical Laboratories' Compliance Plan for the federal Office of Inspector General (OIG), we are required to annually notify all physicians of the following policies, developed to reflect government guidance:
- Medicare national and local medical review policies exist for certain lab tests. Specific information on NCDs and LCDs can be found on the CMS website (https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDs.html), and through the local carrier, Noridian (https://med.noridianmedicare.com/web/jea/policies)
- Medicare and some other payers will not pay for screening tests if the patient displays no symptoms or evidence of disease and may not pay for tests that are not FDA approved or are experimental.
- Medi-Cal fees are equal to or lower than Medicare lab fees.
- All panels (organ and disease or custom) will be billed and paid only when all components are medically necessary.
- Reflex tests and reflex test criteria are listed in the lab manual at http://labmed.ucsf.edu/labmanual/mftlng-mtzn/test/info/2text2.html. For those tests for which non-mandatory reflex tests exist, reflex testing may be declined at the time of order.
- A current Medicare lab fee schedule with CPT (current protocol terminology) codes is available upon request from Clinical Laboratories or directly from CMS at the following website: http://www.cms.hhs.gov/ClinicalLabFeeSched.
Clinical Laboratories consultation is available at 353-1667.
Material contained in this yearly notification is current as of the date published and is subject to change without notice. The OIG believes that a physician who orders medically unnecessary tests and knowingly causes a false claim to be submitted may be subject to sanctions or remedies under criminal or administrative law.
If you have any questions regarding the content of this memo, please contact Cindy Ishizaki, senior supervisor of Quality Assurance and Compliance, at (415) 353-1976 or Cynthia.Ishizaki@