New Regulation Increases Compliance Risk if Denials Are Too High

The final regulation, Requirements for the Medicare Incentives Reward Program and Provider Enrollment, is focused on program integrity issues related to provider and supplier enrollment and maintaining billing privileges. The threat to laboratories centers around CMS’s ability to revoke a provider’s billing privileges based on a laboratory, or any provider or supplier, establishing a pattern or practice of submitting improper claims, including claims denied for a service deemed not reasonable or necessary. Gone are the days when a laboratory could submit its claims for Medicare beneficiaries and deal with denials later. According to a new regulation from CMS, such practice may result in a laboratory demonstrating a pattern or practice of submitting claims that do not meet Medicare requirements and could potentially cause the lab to lose its billing privileges or have its enrollment application denied.

Source: https://www.federalregister.gov/articles/2014/12/05/2014-28505/medicare-program-requirements-for-the-medicare-incentive-reward-program-and-provider-enrollment