Deeper Than the Headlines: Blood Draws and Travel Allowance

Does your organization perform blood draws for laboratory tests? Do your lab technicians who draw blood ever need to travel to obtain the specimen from the patient? For example, the patient might be a nursing home patient or homebound and the technician travels to the patient for the blood draw. Well, under some circumstances, CMS will pay a specimen collection fee and payment of a travel allowance to get to the patient.

As you might imagine complying with the rules for such payments could be in question. And indeed, the OIG thought so and performed some auditing work in this area. They found significant non-compliance.

Specifically, they audited Professional Clinical Laboratory, Inc. (ProLab) and generally found they did not comply with Medicare requirements for billing phlebotomy (blood draw) travel allowances. OIG audited ProLab because it was one of the highest-paid providers for travel allowances in the nation for the period January 1, 2013, through June 30, 2015.

Travel Allowance Background

A travel allowance to collect a sample from a nursing facility or homebound patient may only be claimed by a clinical laboratory when a specimen collection fee is also payable. A specimen collection fee is payable for specimens extracted by a laboratory technician, such as a blood sample drawn through venipuncture, or a urine sample drawn by catheterization. No fee is allowed for samples where the cost of collection is minimal, such as throat cultures, blood draws by capillary puncture or urine collection absent catheterization. The travel allowance is based on the actual distance traveled to each nursing facility or residence on a route until the blood, urine, and micro draws or pick-ups (collectively called specimens) are dropped off at a clinical laboratory, a reference laboratory, or other drop location.

Additionally:

• The allowance cannot be claimed if the technician does not draw the sample but merely performs a messenger service to pick up a blood or urine specimen drawn by a physician or nursing facility personnel.
• At no time is the clinical laboratory allowed to bill for more miles than are reasonable or for miles not actually traveled by the laboratory technician.
• Carriers must prorate travel allowance amounts claimed by suppliers by the number of patients (including Medicare and non-Medicare patients) from whom specimen draws or pickups were made on the same trip.

There are two HCPCS codes used for travel allowances, P9603, and P9604. P9603 is used when the average round-trip to a patient’s nursing facility is longer than 20 miles, paid on a mileage per trip basis. P9604 is used when the average round trip is less than 20 miles, paid on a flat rate per trip basis.

OIG Review

The OIG’s review covered 127,168 claim lines totaling $3,159,036 paid to ProLab for Medicare Part B travel allowances from its Euless, Texas facility between January 1, 2014, and December 31, 2015. Each claim line represented a Medicare travel allowance. OIG reviewed a stratified random sample of 100 claim lines that were each part of a trip.

The OIG concluded that ProLab generally did not comply with Medicare requirements for billing travel allowances. Specifically, of the 100 claim lines in our stratified random sample, 35 claim lines complied with Medicare requirements and 65 claim lines did not (some lines had multiple deficiencies). Based on the OIG’s sample results, they estimated that at least $319,277 for travel allowances for clinical laboratory services claimed by ProLab was not paid in accordance with Medicare requirements.

The CMS guidelines state that at no time will the clinical laboratory be allowed to bill for more miles than are reasonable or for miles not actually traveled by the laboratory technician. Of the 100 claim lines, 56 were part of a trip that did not prorate mileage correctly based on the documentation provided. For 45 of the 56 claim lines, ProLab claimed more prorated miles than their mileage logs supported for a single trip.

Specifically, ProLab claimed up to 66 more prorated miles than had occurred on the trips for these 45 claim lines. ProLab officials told OIG that this was due to a data entry clerk misreading or incorrectly adding the number of miles, the number of draws documented on the mileage logs, or both. ProLab officials also told OIG that they did not prorate the travel allowance mileage using pick-ups because they were not aware of any criteria requiring them to do so. Nine of the 56 claim lines included mileage from a second trip when the mileage count from the claimed trip should have stopped when the specimens were dropped off at a lab. Specifically, ProLab claimed up to 41 more prorated miles than had occurred on the trips for these nine claim lines by including mileage from a subsequent trip. ProLab officials told OIG that sometimes the data entry clerk mistakenly miscalculated multiple trips after blood draws were dropped off. For example, the data entry clerk incorrectly prorated mileage for a single trip to and from the clinical laboratory which included miles not actually traveled by the laboratory technician (i.e., miles after blood draw was dropped off at the clinical laboratory).

The travel allowance is based on the actual distance traveled to each nursing facility or residence on a route until the specimens are dropped off at a clinical laboratory, a reference laboratory, or other drop location. Two of the 56 claim lines were part of a trip where ProLab did not include all of the mileage traveled in the calculation for prorated mileage or just claimed the wrong prorated mileage. ProLab officials were not available to discuss why they did not include the correct mileage in the calculation.

OIG Final Recommendations

The OIG ultimately recommended that ProLab:

• Refund to the Medicare program the portion of the estimated $319,277 overpayment for claims incorrectly billed that are within the reopening period.
• For the remaining portion of the estimated $319,277 overpayment for claims that are outside of the Medicare reopening period exercise reasonable diligence to identify and return overpayments in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.
• Exercise reasonable diligence to identify and return any additional similar overpayments outside of our audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.

Why You Should Perform An Internal Review

If your organization bills for travel allowances associated with specimen collection, it would be wise to study the additional details found in this report and consider performing your own internal review to ensure the billing was in compliance with CMS requirements.