Eli's Hospice Insider

Published on Mon Dec 15, 2014 PDF

New providers will be at a disadvantage.

Medicare will use these six factors to decide whether you get to keep your billing privileges, if it suspects you of “patterns or practices of abusive billing,” according to a new anti-fraud rule :

(A) The percentage of submitted claims that were denied.
(B) The reason(s) for the claim denials.
(C) Whether the provider or supplier has any history of final adverse actions (as that term is defined under § 424.502) and the nature of any such actions.
(D) The length of time over which the pattern has continued.
(E) How long the provider or supplier has been enrolled in Medicare.
(F) Any other information regarding the provider or supplier’s specific circumstances that the Centers for Medicare & Medicaid Services deems relevant to its determination as to whether the provider or supplier has or has not engaged in the pattern or practice described in this paragraph.

Clarifications On How It Works

The “percentage of claims denied” criterion will be based on the NPI listed on the claim, CMS explains in the final rule issued Dec. 3. Also, “a provider or supplier’s claim denial that has been both: (1) fully (rather than partially) overturned on appeal; and (2) finally and fully adjudicated will be excluded from our … determinations,” the agency says in the rule published in the Dec. 5 Federal Register.