I've seen some really incredible performance by AI like GPT4, being excellent at summarizing articles (up to 2000 words) and surprisingly good at suggesting PhD topics, PhD outlines, and even PhD first chapter of a PhD. (See GPT4 suggest a Medicare lobbying strategy here and advise Hollywood studios on investments here.)
However, I've repeatedly seen it fail badly with even standard Medicare policy questions.
For example, there is the lab referral billing 30/70 rule (based on SSA 1833(h)(5)(A); see here). Below, GPT4 completely blows this, making up a nonexisting rule and then getting the 30/70 rule exactly backward initially.
If you want to see the fiasco for yourself, below.
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[Correct rule is shown in blue several screens down in the Q&A].
There is a special rule about labs billing medicare for send-away tests (referral tests). I think they can bill Medicare if they bill themselves for no more than 30% of send-away tests, or that is, if they perform themselves 70 of every 100 tests they bill. I think it's the 30/70 rule but it might be something else.
ChatGPT [all wrong]
The rule you are referring to is known as the "14/90 Rule," also called the "anti-markup rule" or "referral laboratory rule" in the context of Medicare billing. This rule was introduced by the Centers for Medicare & Medicaid Services (CMS) to regulate the billing practices of clinical laboratories.
According to the 14/90 Rule, a clinical laboratory can bill Medicare for referred tests (send-away tests) if it meets the following criteria:
- The referring laboratory must perform at least 14 different tests for Medicare patients.
- The number of referred tests must not exceed 90% of the total number of tests billed to Medicare.
In other words, the referring laboratory should perform at least 10% of the tests billed to Medicare to be eligible for reimbursement for referred tests. The 14/90 Rule aims to prevent overcharging and abusive billing practices by ensuring that laboratories have a significant portion of their testing services performed in-house.
Please note that this information is accurate as of my last knowledge update in September 2021. Rules and regulations may have changed since then. It is always a good idea to consult the latest CMS guidelines or a healthcare compliance professional to ensure compliance with the most current regulations.
User
I think you are in error. I found documents on the 30/70 rule or 30% rule. I found nothing on Google for any 14/90 rule anywhere. SSA 1833(h)(5)(A).
ChatGPT [wrong again]
I apologize for the confusion, and I appreciate your diligence in seeking accurate information. It seems I made an error in my previous response.
You are correct; the rule you are referring to is called the "30/70 Rule" or "30% Rule." It is related to the billing of referred tests by clinical laboratories for Medicare patients. According to the rule, a laboratory can bill Medicare for referred tests if it meets the following criteria:
- The referring laboratory must perform at least 30% of the tests it bills to Medicare in-house.
- The number of referred tests must not exceed 70% of the total number of tests billed to Medicare.
This rule is designed to prevent overcharging and abusive billing practices by ensuring that laboratories have a significant portion of their testing services performed in-house.
Again, I apologize for the confusion in my earlier response, and I thank you for bringing it to my attention. As with any regulation, it is always a good idea to consult the latest CMS guidelines or a healthcare compliance professional to ensure compliance with the most current regulations.
User
No, you are closer but still wrong. The lab must itself perform and bill at least 70% of tests. It must not refer out more than 30% (if it bills them itself).
ChatGPT
I apologize once again for the confusion in my previous responses. You are correct, and I appreciate your patience in seeking accurate information.
The 30/70 Rule or 30% Rule you are referring to states that a laboratory can bill Medicare for referred tests (send-away tests) if:
- The referring laboratory performs at least 70% of the tests it bills to Medicare in-house. [correct]
- The number of referred tests (send-away tests) must not exceed 30% of the total number of tests billed to Medicare. [correct]
This rule is designed to prevent overcharging and abusive billing practices by ensuring that laboratories have a significant portion of their testing services performed in-house.
Please consult the latest CMS guidelines or a healthcare compliance professional to ensure compliance with the most current regulations, as rules and regulations may have changed since my last knowledge update in September 2021.
