Latest Publications


CMS Takes First Step to Reduce Payments for Clinical Laboratory Tests

CMS recently published a proposed rule that would substantially revise the methodology used to pay for clinical laboratory tests that continue to be compensated separately by Medicare. Medicare Program; Medicare Clinical...more

OIG Nixes Arrangements Involving Free Tests

Labs Attempt to Counter Exclusive Lab Arrangements - With increasing frequency, clinical laboratories have found themselves unable to receive any payments for tests performed for individuals whose third-party insurer...more

ABN Flunks Medicare Test

In Int’l Rehab. Sci. v. Burwell, No. 08-cv-05442 (W.D. Wash. Feb. 13, 2015), the court found inadequate an advance beneficiary notice (ABN) which stated that “Medicare has not established coverage criteria... or does not...more

4/8/2015  /  CMS , Medicare , Notice Requirements

Laboratory Discount Arrangements Survive Antikickback Statute Scrutiny

There has been question for some time whether in evaluating certain discount arrangements involving clinical laboratory tests under the federal antikickback statute (FAS), discount charges should be measured against the...more

Medicare OPPS Lab "Packaging" Policy Raises Bundle of Issues

In previous Payment Matters articles, we described a policy included in the 2014 hospital outpatient prospective payment system (OPPS) final rule that would “package” certain clinical laboratory tests into OPPS, and CMS...more

CMS Provides Guidance Regarding OPPS "Packaging" of Clinical Laboratory Tests

In a previous Payment Matters article, we described a new CMS policy under which, effective January 1, 2014, hospitals would no longer be permitted to bill Medicare separately for clinical laboratory tests for hospital...more

CMS "Packages" Clinical Laboratory Tests Into Outpatient Prospective Payment System

Hospitals Lose Right to Bill Separately for Laboratory Tests for Outpatients - As part of its calendar year 2014 hospital outpatient prospective payment system (OPPS) policy changes, the Centers for Medicare & Medicaid...more

Lawsuit Based on Kickback, Stark Law Violations Sustained; Civil Suit Offers Additional Option to Counter Competitor's Illegal...

Hospitals, laboratories, and other health care providers that rely on referrals from other health professionals may encounter situations where competitors have entered into arrangements with physicians or other referral...more

Pathology Lab That Cannot Demonstrate Adequate Physician Orders Suffers Medicare Loss

Much has been written regarding various Medicare policies that may cause a clinical laboratory to suffer the resulting financial consequences when a test requested by a physician is found to be not medically necessary, most...more

Revision to CMS Manual Related to Anatomic Pathology Raises Additional Global Billing Issues

The Centers for Medicare & Medicaid Services (CMS) recently amended Medicare Claims Processing Manual (MCPM) provisions related to payment for anatomic pathology services to specifically address submission of such claims on a...more

Self-Audit Results Found Sufficient to Sustain False Claims Act Complaint

District Court Finds That Medical Group’s Failure to Further Investigate Audit Results May Violate Requirement to Return Overpayments - Background - Internal audits of third-party payment claims – frequently...more

Payment Matters: CMS Final Rule Eliminates Requirement for Signed Laboratory Requisition: The Good, the Bad and the Unknown

In a previous Payment Matters article, we reported that CMS had proposed to retract its rule requiring a physician or qualified non-physician practitioner (NPP) to sign the requisition for a clinical diagnostic laboratory...more


Payment Matters: CMS Proposes Rule on Signature on Laboratory Requisitions – A Trip Back to the Future

In a previous Payment Matters article, we reported that CMS had instructed its Medicare contractors not to enforce the requirement that it had included in the Medicare Physician Fee Schedule Rule (MPFS) for calendar year...more


Payment Matters: CMS Sign-Off - No Enforcement of Physician Signature Requirement on Lab Requisitions

As part of the Medicare Physician Fee Schedule final rule for calendar year 2011, the Centers for Medicare & Medicaid Services (CMS) required a physician or a qualified non-physician practitioner (NPP) to sign the requisition...more


Health Law Alert: Q&A: Regarding EHR Rules

Q: Our laboratory is considering offering physicians the opportunity to request tests and receive test results electronically. What are some of the important regulatory issues we should consider? A: Any such arrangement...more


Forget What I Said – Medicare Date of Service Rule May Not Require Separate Line-Item Claims for Pathology Services

In our June 12, 2009 Payment Matters, we commented on a recent change in the Medicare Claims Processing Manual (MCPM) that would require claims for physician pathology services to be billed as separate line items if the two...more

8/18/2009  /  CMS , Medicare

Medicare Permits Ambulatory Surgical Centers to Submit Claims for Services of Physicians and Practitioners

A recent revision to the Medicare Program Integrity Manual (MPIM) states that physicians and non-physician practitioners may reassign benefits to an ambulatory surgical center (ASC), if the arrangement complies with a...more

Makin' a Rule, Changin' it Twice: CY 2009 Physician Fee Schedule Further Modifies CY 2008 Changes to Diagnostic Test Billing Rules

CMS revised Medicare billing rules for diagnostic tests as part of its CY 2009 Physician Fee Schedule. These changes modified earlier changes made in the CY 2008 Physician Fee Schedule. Ober|Kaler's Robert E. Mazer and Mark...more

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