Billing BCBS As Clinical Laboratory
You should be billing the state where the ordering provider is located. So as you say, if the lab is in Georgia, but the ordering provider is in Texas, you bill BCBS of Texas. I am not understanding why the laboratory would be "reading" results of a specimen? Additionally, if the lab is a non-par provider, they will need to attain non-par provider numbers from each BCBS plan. Here is an excerpt on the change that occurred in 2012. Sadly your friends larger problem is that the payment for their services will be going directly to the patient, even with an assignment of benefits. Feel free to reach out to me directly if you have additional questions.
However, for laboratory services effective October 14, 2012, BCBS now requires that laboratories bill the BCBS Home plan, which has been defined as where the pathology specimen was drawn. This change has no impact if the specimen is drawn in the same region as the laboratory. However, for laboratories that process out-of-state specimens, this policy change can present substantial issues.
For example, a patient from Florida has a specimen drawn at their local physician’s office. The specimen is sent to a lab in Georgia for processing. Before October 14, 2012, the Georgia laboratory sent their claim to their local GA BCBS plan which would process the claim via reciprocity with the beneficiary’s plan (FL BCBS). GA BCBS paid the laboratory directly at the in-network rate as long as the Georgia laboratory was a participating provider with Georgia BCBS.
Here is what the changes mean for this example. Effective October 14, 2012:
1. The GA lab must now bill the regional/state BCBS plan where the specimen was taken, in this case, the Georgia lab must bill Florida BCBS.
2. Unless the Georgia lab is a participating provider with FL BCBS, FL BCBS will pay the lab at out-of-network rates.
The burden is on the laboratory to identify the correct BCBS plan for billing based on the state where the specimen was taken. This is done by identifying the state of the referring physician and billing that state’s BCBS plan. The NPI number of the referring physician must be on the claim.
The laboratory must contract with the BCBS plans of the states where the referring physicians draw specimens. If the lab is not participating with those states, patients will be responsible for higher out-of-network co-payments.
It has been noted that many BCBS plans will not contract with out-of-state laboratories and that some carriers have ignored the patient’s assignment of benefits and have paid the patients directly, causing numerous problems for both labs and patients.
Have a Happy 4th!!