Test Panels / Profiles and Reflex Tests
These details are designed to assist both the laboratory user and the laboratory in complying with federal regulations, and are provided as part of our overall compliance program. The U.S. Office of the Inspector General (OIG) has recommended that laboratories inform physicians and other providers who use their services.
The laboratories’ medical directors are available to provide assistance in selecting appropriate tests for a patient, condition, or other clinical situations where an ordering provider needs assistance. Physicians or others with questions may contact Client Services for additional information.
Organ or Disease-Oriented Panels / Profiles
These are groups of medically-necessary laboratory tests that have been defined by the American Medical Association (AMA) and have been approved for reimbursement by CMS. Each test in the panel may be ordered separately if the entire panel is not desired.
Custom Panels / Profiles
These are groups of tests that are commonly ordered together in certain situations. These may be institute, specialty, or provider-specific.
Custom panels/profiles are neither defined by the AMA nor approved by CMS. Each test in the panel may be ordered separately if the entire panel is not desired.
Cleveland Clinic Laboratories does not offer custom panels for clients; however, clients may choose to build profiles on their own with the listed risks applicable to their ordering practices.
These are tests that reflex to one or more additional tests based on criteria applied to the results of the first test. An example is a screening test in which a presumptive positive result in the initial test reflexively orders to confirmatory tests.
Reflex tests are clearly identified as such in our online Test Directory.
By using custom profiles, providers need to be aware of the following:
1. When ordering tests for which Medicare reimbursement will be sought, the ordering physician should only order those tests that are medically necessary for each patient
2. Utilizing a custom panel/profile may result in the ordering of tests for which Medicare, or other federally-funded payers, may deny payment.
3. Only those tests that are medically-necessary in diagnosing or treating a patient’s condition should be ordered.
- When all of the components of a custom profile are not medically-necessary, the ordering provider should order only individual tests (or a less inclusive profile) that are medically necessary in diagnosing or treating a patient.
4. The Office of Inspector General (OIG) takes the position that a physician who orders medically-unnecessary tests, for which Medicare reimbursement is claimed, may be subject to civil penalties.