Talk to Us About Diagnostic Test Anti-Mark Up Statutes
Under the old Centers for Medicare and Medicaid Services (CMS) rules adopted in 2007, physicians were allowed to mark up the technical component (TC) or professional component (PC) of a diagnostic test purchased from an outside supplier, as long as the mark up did not exceed certain thresholds, including:
- The supplier's net charge to the billing physician or other supplier
- The billing physician or other supplier's actual charges
- The fee schedule amount for the test that would be allowed if billed directly by the supplier
Effective January 1, 2009, complying with new Medicare rules for billing for diagnostic tests became a lot more complicated. New CMS rules now prohibit applying a mark up to the technical component or the professional component of the diagnostic test purchased from an outside supplier with whom the physician shares a practice, under the following definition:
- The prescribing physician furnishes at least 75 percent of all orders to the diagnostic lab
- The TC or PC tests are conducted in the same office (building) of the billing physician
Will the New Anti-Mark Up Regulations Affect Your Bottom Line?
In effect, the new CMS anti-mark up rules prohibit many physicians from forming a strong relationship with a particular diagnostic testing center for the purpose of referring tests for the technical or professional components of the diagnostics. If such a partnership or investment relationship is deemed to exist, the referring physician can no longer mark up the cost of the diagnostic tests to cover overhead expenses associated with billing the patient through Medicaid or Medicare. Physicians may be charged with fraud and ordered to repay all moneys billed for diagnostic tests through CMS.
If these new CMS anti-mark up rules have impacted your billing practice, or if you have questions regarding regulatory compliance with the diagnostic tests anti-mark up statutes, talk to a health law attorney at Kerr, Hendershot & Cannon right away. We have extensive experience in all legal areas relating to physician billing, independent labs and emergency rooms and Stark self-disclosure laws.
The Houston Health Care Fraud Lawyer You Can Rely On
From our offices in Houston, our lawyers represent doctors, clinics and health care providers in communities throughout South Texas. Contact us to arrange a consultation with an attorney on our health law team today.
