News and Insights

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Bob Milligan presented a lecture to law students in the Health Law and Policy course at the Arizona State University Sandra Day O’Connor College of Law. The lecture, “Health Law and Policy: The ‘Fraud and Abuse’ Rules,” took place on November 20, 2012.

Mr. Milligan focused his lecture on fraud and abuse rules as they apply to the upcoming health care reforms, the cost of enforcing the rules vs. the monetary benefits achieved with enforcement, and the changing face of health care law.

Mr. Milligan has an AV Peer Review rating with Martindale-Hubbell. In addition, he has been continuously listed in “The Best Lawyers in America” since 2001, and has been named a Southwest Super Lawyer since 2007.

For details of Mr. Milligan’s presentation, click here: Health Law and Policy

Effective January 1, 2012, Medicare no longer paid for the technical component of diagnostic MRI, CT, nuclear medicine, or PET tests unless the practice is accredited by one of the following three organizations: (1) American College of Radiology; (2) the Intersocietal Accreditation Commission; or (3) The Joint Commission. Practices that bill Medicare for these modalities should carefully review and consider the implications of this accreditation requirement to ensure continued compliance with Medicare’s reimbursement rules, the Anti-Markup Rule, and the Stark Law.

 To become accredited, practices must meet standards established by an accrediting organization. Each organization assesses, among other things, the qualifications of physicians who supervise the technical component of the diagnostic test. Practically speaking, two of the three accrediting organizations require the supervising physician to be a radiologist with expertise in the particular modality.

Medicare’s diagnostic testing billing requirement permits any physician to supervise the technical component of a diagnostic test. However, with this accreditation requirement the supervising physician for accreditation purposes may also need to be the supervising physician for billing purposes. The fact that many practices contract with an outside radiologist for accreditation purposes could make compliance with the Anti-Markup Rule and the In-Office Ancillary Services (“IOAS”) exception to the Stark Law exceedingly difficult.

At the risk of oversimplification, the Anti-Markup Rule prohibits a practice from billing Medicare for the technical and professional components of diagnostic tests unless the practice complies with one of two tests, which will be difficult for most practices to comply with when the accreditation requirement goes into effect. Further, the IOAS exception to the Stark Law is the main exception to the Stark Law that permits practices to bill Medicare and Medicaid for ancillary services, including diagnostic imaging tests and nuclear medicine. Compliance with the IOAS exception’s physician supervision requirement is more difficult with this accreditation requirement.

 All practices that seek reimbursement for the technical components of MRI, CT, nuclear medicine, or PET should carefully review the implications of the accreditation requirement.