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Proposed rule goes too far

Proposed rule goes too far

WASHINGTON - Providers with high error rates could lose their billing privileges if a proposed rule takes effect.

The Department of Health and Human Services published a proposed rule in the Federal Register April 29 that contains a provision that would expand Medicare's authority to revoke billing privileges to cases where the provider “has a pattern or practice of billing for services that do not meet Medicare requirements.”

That's going too far, say stakeholders.

“This is not revocation for fraud,” said Steve Azia, counsel at Washington, D.C.-based Baker Donelson. “A provider could lose billing privileges based on an error rate that's often overturned.”

The provision basically does away with due process, said Azia.

“What's the point of the appeals process if this goes through?” he said.

The criteria for revoking billing privileges are still unknown. The provision outlines a likely scenario—revocation based on a significant number of denials for medical necessity over time—but seeks input on the number of claim denials that might trigger the review, and the length of time over which those denials occur. CMS also seeks input on whether the amount of time a provider was enrolled in Medicare before the denials should be taken into consideration.

“They're not laying out guidelines,” said Azia. “They're asking for this authority, but they're also asking for input on the standards. It's very important for the provider community to weigh in and protect their rights.”

Providers have until June 28 to comment on the proposed rule. To comment electronically, providers can go to


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