10 checks to run on your in-office lab before the 2027 rates hit

CMS said Aug. 28 that it has blocked or recovered more than $1.6 billion in potentially improper Medicare laboratory payments, including $732 million tied to 157 lab providers revoked from the program. An investigation of about 600 labs produced 185 payment suspensions. The agency credited artificial intelligence and machine learning models running against fee-for-service claims, looking for billing patterns that fall outside the norm.

Almost none of that is about physician office labs. The cases CMS described involve shell operations billing for tests nobody performed. But the analytics do not know the difference at the front end. They run against every lab claim in the file, including the 20 waived tests your practice ran last Tuesday, and the practices that get pulled into review are frequently the ones whose paperwork cannot answer a simple question quickly.

The Clinical Laboratory Fee Schedule resets Jan. 1 on top of all of it, with payment for roughly 800 tests eligible to drop as much as 15 percent. An hour with the certificate, the package inserts and 30 claim lines will tell you more than any vendor assessment. Here are 10 places to start.