Wiki HELP w/Laboratory Billing Oklahoma

[straitfan]

we have found a number of physician offices in Oklahoma billing for laboratory services on a, i would say, a 3rd party billing platform. the lab is charging them a flat fee for the lab services and the physician office is billing for the actual laboratory code.

this does not seem kosher? the doc is being reimbursed very handsomly for services they are not performing and they are not a high complex lab. i had one doc tell me Oklahoma still has a loophole in the law allowing him to do this.

i would appreciate any explanation that would help me better understand this practice.

 

[slrollings]

This does not sound kosher to me either. The CMS1500 has to have the correct Box 24B place of service, (where the test was run- not where the patient was). If it was actually drawn and run in the office, then yes, you can use a POS code 11, but if it was drawn in the office and actually tested at the lab, you have to use the POS code of 81 (independent lab).
The same for Box 32 - it has to show where the test was run, not where the patient is. This address and NPI, etc needs to be tied to the correct CLIA number.
I couldn't say about OK loopholes, but this is what the Medicare guidelines say.

Please reference Medicare Claim Processing Manual 100-04, chapter 16.
Hope this helps.

 

[straitfan]

Lab Billing Oklahoma

Thanx. here's the interesting thing about this. the practice only bills commericial claims in this manner. they leave out medicare/medicaid claims. the lab actually bills medicare/medicaid claims and the practice bills for the commercial. they were advised to do it this way by the lab. i think the lab knows this is against medicare rules. i'm not sure why it's kosher for commercial claims.

any comments from a practice in OK that is currently in a similar situation, i would appreciate any input. thx.

 

[slrollings]

I got to thinking about this later last night and I do know of labs that do this. Like you said, it's for commercial ins only. I don't think there is anything to prevent them from doing this. This helps the labs to not have to contract with the 1000's of carriers and still get paid. It's actually a win-win because the patient is happy that their claims are paid, the doc is happy because he's getting paid, the lab is happy because they get paid by the doc. The only one it hurts would be the ins company, because if the lab isn't contracted and the doc is, they probably pay more to the doc instead of denying for out of network.