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2008 CMS Anti-Markup Rule and Effect on Pod Labs

We Will DiscussDifference between pod labs and other types of contractual joint ventures (CJVs)History of CAP activities against CJVsOverview of Anti-Markup RuleOverview of CAP's recommendations and strategiesExamples from CMS and your questions. AcronymsAPAnatomic PathologyCJV Contrac

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2008 CMS Anti-Markup Rule and Effect on Pod Labs

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    1. 2008 CMS Anti-Markup Rule and Effect on Pod Labs David N. Henkes, MD, FCAP Chair, Professional Affairs Committee

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    23. Examples from CMS on the Anti-Markup Rule and Your Questions Donna J. Meyer, JD Assist. Director, Professional Affairs

    24. Example #1 from CMS Facts: A urology group contracts with a leasing company that supplies a technician and a pathologist to perform testing on prostate samples. All work is done at a space that the urology group rents exclusively for the sole purpose of providing pathology services for the group’s patients. Outcome: Anti-markup provisions apply to both the TC and the PC, even though the space qualifies as a “centralized building” under the Stark Law.

    25. Example #2 from CMS Facts: Same as Example 1, except that the TC is performed by a technician that is an employee of the group practice and the PC is performed by a pathologist who is an independent contractor of the group practice. Outcome: The anti-markup provisions again apply to both the TC and the PC. It does not matter that the technician is an employee and the pathologist is an independent contractor because the work was not performed in the office of the billing group practice.

    26. Example #3 from CMS Facts: A physician in a group practice orders a diagnostic test and a technician who is a part-time employee of the group performs the test in the group’s office. A physician who is an independent contractor of the group performs the PC in the group’s office. Outcome: The anti-markup provisions do not apply to the group’s billing of the TC or the PC because they are performed in the office of the billing physician.

    27. Example #4 from CMS Facts: Same as Example 3, except that the independent contractor physician performs the PC in his or her home and reassigns the right to payment for the service to the group. Outcome: The group’s billing of the TC is not subject to the anti-markup provision but the group’s billing of the PC is subject to the anti-markup provision because the work was not performed in the office of the billing physician.

    28. Example #5 from CMS Facts: A group practice orders a diagnostic test from an independent laboratory. The lab performs the test and contracts with a physician to perform the PC. The lab bills Medicare for both the TC and PC . Outcome: The lab is not subject to the anti-markup provisions because the lab did not order the test. It does not matter where the physician performs the PC.

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