Medicare Claims for Duplicate Laboratory Services Continue to Be Denied
The Centers for Medicare & Medicaid Services (CMS) says it will continue to deny claims for duplicate laboratory services unless the tests are deemed...
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On April 4, the Centers for Medicare and Medicaid Services issued a final rule making policy and technical changes to the Medicare Advantage (MA) program, Medicare Prescription Drug Benefit program, Medicare cost plan, and Programs of All-inclusive Care for the Elderly for contract year 2026.
The final rule seeks to close MA loopholes that have adverse consequences for providers and enrollees. It clarifies the definition of “organization determination,” which is a decision subject to MA appeal and notification requirements, to include MA plan decisions made concurrent to the enrollee’s receipt of services. Additionally, it codifies existing guidance that requires plans to give both a provider and an enrollee notice of a coverage decision whenever the provider submits a request on behalf of an enrollee. Finally, it modifies existing regulations to clarify that an enrollee’s liability to pay for services cannot be determined until an MA organization decides on a contracted provider’s claim for payment.
CMS notes that certain provisions from the proposed rule, such as the annual health equity analysis of utilization management policies and artificial intelligence guardrails, will not be finalized at this time.
CAP Submits Comments on Proposed 2027 Medicare Physician Fee Schedule
The College of American Pathologists (CAP) submitted comments to the proposed 2027 Medicare Physician Fee Schedule (PFS), addressing proposals that...
CMS Announces Phased-In Reduction of Medicare Payment Rates for Lab Services
The Centers for Medicare & Medicaid Services (CMS) plans to reduce preliminary Medicare payment rates for laboratory services.