Medicare Compliance & Reimbursement

Fraud & Abuse:

OIG EYES EXCESSIVE CHARGES

Clarification may be in store on what could get providers excluded from Medicare.  Providers confused about how much is too much when it comes to charge-based Medicare payments could soon get some guidance from the HHS Office of Inspector General. In a Sept. 15 Federal Register notice, the OIG says it's planning to clarify the regulations that govern when it can exclude a provider from Medicare and other federal health care programs for billing for amounts that are substantially in excess of its usual charges. The proposal includes a formula that defines "usual charges" as well as a bright line for "substantially in excess" that's set at 120 percent of usual charges. The watchdog agency invites comments on the proposal, which are due Nov. 14.
The exclusion rule would primarily affect providers of Part B services, including clinical laboratory services, durable medical equipment and supplies, and drugs. It could also play into outlier enforcement - a current OIG hot button. Physician services, however, are outside the scope of the rule.    To see the rule, go to www.access.gpo.gov/su_docs/fedreg/a030915c.html.
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