by Jared Staheli
July 9th, 2015
Unless a laboratory, physician, or medical group accepts assignment, the carrier makes no Part B payment for laboratory tests paid on the laboratory fee schedule. Laboratories, physicians, or medical groups that have entered into a participation agreement must accept assignment. Sanctions of double the violation charges, civil money penalties (up to $2,000 per violation), and/or exclusion from the program for a period of up to five years may be imposed on physicians and laboratories, with the exception of rural health clinic laboratories, that knowingly, willfully, and repeatedly bill patients on an unassigned basis. However, sole community physicians and physicians who are the sole source of an essential specialty in a community are not excluded from the program. Whenever a carrier is notified of a sanction action for this reason, the carrier does not pay for any laboratory services unless the services were furnished within 15 days after the date on the exclusion or suspension notice to the practitioner, and:
• It is the first claim filed for services rendered to that beneficiary after the date on the notice of suspension or exclusion; or
• It is filed with respect to services furnished within 15 days of the date on the first notice of denial of claims to the beneficiary. (Fifteen days are allowed for the notice to reach the beneficiary.)
Carriers refer questions on payment procedures to the Sanctions Coordinator in the RO.
Carriers process laboratory claims inadvertently submitted as unassigned as if they were assigned. (See §50.)
For purposes of this section, the term assignment includes assignment in the strict sense of the term as well as the procedure under which payment is made, after the death of the beneficiary, to the person or entity that furnished the service, on the basis of that person’s or entity’s agreement to accept the Medicare payment as the full charge or fee for the service.