Medicare’s Anti-Markup Rule – CMS final two options

30 October 2008 CMS released the 2009 MFPFS. The 2009 MFPFS, in the application of the anti-markup rule to provide some diagnostic testing services, on January 1, 2009, the CMS two ; alternative tests to determine the applicability of the anti-markup rule.

Final Anti-Markup Rule

Specifically, the following principles determine the applicability of the anti-markup rule:

(1) Option 1 – “substantially all test.” Provisions should first be analyzed under this alternative. If the performing physician (ie, the doctor who oversees TC or performing the computer, or both) performs principle all (75 percent) of his or her professional services for the billing physician or other supplier, the services are not covered anti-markup rule payment Limited & # xE4; limitations imposed. If “substantially all” service requirement is not met, an assessment according to Option 2 can be applied.

(2) Option 2 – “Site of Service Test.” TCs are implemented and monitored, and computers out of, “the office of the billing physician”, which contains the “same building”, a employee or an independent contractor physicians avoid the anti-markup payment limitation.

These alternative tests measure whether performing or supervising physician “shares a practice with the billing physician or other supplier. En la stronger is no longer required to only work for a medical practice without a physician need only “have a practice with a lee ; anchors or physician organization. This change adjusts certain provisions of the Stark group practice definition of anti-markup provisions.

Moreover ingåri 2009 MFPFS to a billing physician or other supplier meets Option 1 if he or she has reasonable grounds to believe, when he l & # xE4; mnar an application, which is either (1) performing doctors furnished practically all of his or her professional services through the billing physician or other supplier & # xF6; r for 12 months prior to the month in which the action took place, or (2) utfö r doctors are expected to provide virtually all of his or her professional services through the billing physician or other supplier in the Lecture ; The following 12 months (including the month the service is performed).

Regarding option 2, CMS adjusts the spot test with the Stark Law “same building” test by clarifying that a doctor or other provider may have more than an “office of the billing physician or other supplier”. Such an area is one in which the ordering physician or ordering provider regularly supplies wo rd (and in terms of physician organizations and group practices, the space where the ordering physician performs much the full spectrum of patient-cha ; Left by ordering physician provides generally). In addition, CMS requires the physician to monitor TC be an owner, employee or independent contractor of the billing physician or other supplier & # xF6; r. In the case of the computer, it must be performing physician be an employee or independent contractor of the billing physician or supplier.

As a practical matter, the last against labeling rules allow the use of joint arrangements between Space Imaging doctors present in “same building”. Yet, CMS notes that the centralized building sites bring concerns about over-exploitation and is not allowed for tillhandah & # xE5; llande of diagnostic tests. CMS also warns that despite its flexibility has been the case with the current use of IOAS exception under Stark and may make future changes.

Of particular relevance to the physician providing imaging in reliance on option 2 must be both TC Implemented & # xF6; race and monitored in the “office of the billing physician or other supplier” ( “same office requirement). While the Stark law generally to ; mpar Medicare coverage and payment regulations on the control of the tests ( “Medicare coverage), providers seeking to rely on Option 2 be meet the same office requirement. This is because CMS believe that the same office requirements are necessary to reduce the risk of overexploitation and programs abuse.

Contracts within the framework of the anti-markup provisions are subject to restrictive payment limitations, so that payment to the billing entity will be limited to the lesser of: (1) performing physician or other supplier’s net charge to the billing fö ; COMPANY, (2) the billing entity actual cost, or (3) The fee schedule amount for the test that would happen if the performing physician or supplier billed directly.

Significantly, the net debit amount must be determined without reference to a fee that is supposed to reflect the cost of equipment or space leased distributed to the performing supplier by or through the billing physician or other supplier. Therefore, the billing physician or other supplier to recover only the cost of salaries and allowances paid to the performing provider of TC or PC. As a result, the billing physician or other providers who require an anti-markup rule will likely be compensated by not even taking ; cker costs of providing the services.

Below are two examples of the final anti-markup provisions and their application to the imaging arrangement:

(1) Independent radiology group practice manager arrangement. A doctor in a multi-specialty group practice orders a radiology technician and part-time employee performing X-ray of the group’s offices. Ordering Process physicians work exclusively for multi-specialty group and oversees the test in the group’s offices. A radiologist, who is an independent supplier of multi-specialty group practice, the computer performs the test in the group’s office and reassign their right to payment to the group. Radiologist providing professional services to several groups and hospitals in the area. He performs about 20 percent of its professional services for multi-specialty group practice. The anti-markup rule does not apply to the group’s billing of the TC as the supervising physician (ie, they carry a doctor) “share a practice of billing the group as he performs at least 75 percent of its professional services group. In the case of the computer in the test, the independent suppliers , r (ie, the performing doctor) does not work in virtually all of its professional services to the group (he performs about 20 percent). Thus case an assessment according to Option 2. In the “site of service” test, the anti-markup rule does not apply because the performing radiologist fö rutsatt interpretation on the spot in the group’s offices.

(2) IDTF agreement. A doctor orders a diagnostic test from an IDTF. The IDTF bills globally for the test (TC and PC). The anti-markup rule does not apply because the IDTF did not order the test, but had ordered it from an outside doctor.

IDTF Performance Standards for Mobile Imaging Providers

The 2009 MFPFS CMS finalized its earlier proposal by requiring mobile IDTFs register and Bill Medicare directly for the provision of TC services. However, CMS does not require testing mobile bill directly for their services when these services are provided “arrangement” with the hospital . This final rule prohibits many common arrangement in which mobile units rent diagnostic testing equipment and technologies that lead doctors and counting fö r such tests in their offices. Summarize, effective 1 January 2009, all mobile devices that provide diagnostic testing services must register with the Medicare program and bill directly to the cha Left as if they are not billing “under arrangement” with a hospital.

Conclusion

Through a series of legal measures, CMS has been targeted diagnostic imaging arrangements. Diagnostic imaging, PACS, and providers should be alert to the development of future rulemakings, which may significantly affect the structure of the m & # xE5; nga existing imaging arrangements. As a result, we recommend the providers to include procedures in their current contract that will allow these events to apply a stricter regulatory framework. Finally, the regulatory changes discussed in this article are not likely to CMS last word on diagnostic tests. Suppliers should be aware of this before they come into structures that can not be rolled out or changed.

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