Wiki lab billing by doctor

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I have a lot of denials for CPT 81002 as included with E/M billed on the same day. Can this urinalysis be billed with an E/M?
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My provider has question. Can he bill for lab codes? Lets say if he were to get the lab company that runs the test charge his account. Can he then in turn bill the patients commercial insurance company for what the codes the lab would have billed?

I thought hat was a no but he wanted me to confirm with other biller and coders. Please help me with this thank you.
 

thomas7331

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The arrangement you're talking about here is legal - a physician can purchase the technical or professional component of a diagnostic service performed by an outside entity and then bill for it themselves. There's a box on the CMS-1500 form that allow you to indicate that this is a 'purchased service', and your physician would indicate the name, address and NPI of the supplier of the service in box 23. However, the anti-markup laws require that the physician may not bill an amount that is more than was paid for this service. This is all detailed in the Medicare Claims Processing Manual, Chapter 13, section 30.2.9.

So it can be done, but there really is no advantage to doing this, yet there is a significant downside in that the physician would be taking on all of the administrative costs and risks involved of billing and collecting, (e.g. working denials, billing patients). As I see it, your physician would be taking on a financial risk that has no potential to offer any rewards in return.
 

Orthocoderpgu

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This doesn't make any sense. Why would you want to increase your workload for work that must be done outside of the clinic? While this may not be a direct violation of the STARK laws, it sure looks as if the physician wants to go that direction. I would stay away from this at all costs. I'm sure others will weigh in with more specificity, but this is a very bad idea.
 
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This doesn't make any sense. Why would you want to increase your workload for work that must be done outside of the clinic? While this may not be a direct violation of the STARK laws, it sure looks as if the physician wants to go that direction. I would stay away from this at all costs. I'm sure others will weigh in with more specificity, but this is a very bad idea.
Thank you, I was thinking the same thing. Apparently, some other billing company is telling him he can do this and get more money. Just so he can sign a contract with them. Thank you so much
 

Orthocoderpgu

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Bingo! A doctors not going to do this unless there is some benefit for them, otherwise they would not want to do it. Your doctor wants to get more money. That itself is a clue that legally you don't want to get involved. There is no such thing as money for nothing.
 
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Bingo! A doctors not going to do this unless there is some benefit for them, otherwise they would not want to do it. Your doctor wants to get more money. That itself is a clue that legally you don't want to get involved. There is no such thing as money for nothing.
Exactly!!! Thank you I was thinking the exact same thing. I don't like anything shady. I'll stay away and I'll try to convince him not to take that route.
 

lcolborn

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Further more, to be able to bill the Commercial Ins. , you have to have a CLIA certificate and all Gov't Entities needs to be filed by the Lab Company. The CLIA Wave test are ok, but not regular labs/path.
Most likely the Lab is trying to give him a Client price and a contract.
 
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Further more, to be able to bill the Commercial Ins. , you have to have a CLIA certificate and all Gov't Entities needs to be filed by the Lab Company. The CLIA Wave test are ok, but not regular labs/path.
Most likely the Lab is trying to give him a Client price and a contract.
That's what I thought the CLIA waived test are ok but not the path. The third party billing company wants him to get the lab company to bill him the physician price so then he can in turn bill for the commercial companies and the labs can bill for the Gov't ones. Because they know he wont get much from them. All of this sounds shady to me honestly. If you have any more insight please let me know. The more I have to prove to him that this is a bad idea the better. Thanks
 
Messages
6
Location
Kingwood, TX
Best answers
0
The arrangement you're talking about here is legal - a physician can purchase the technical or professional component of a diagnostic service performed by an outside entity and then bill for it themselves. There's a box on the CMS-1500 form that allow you to indicate that this is a 'purchased service', and your physician would indicate the name, address and NPI of the supplier of the service in box 23. However, the anti-markup laws require that the physician may not bill an amount that is more than was paid for this service. This is all detailed in the Medicare Claims Processing Manual, Chapter 13, section 30.2.9.

So it can be done, but there really is no advantage to doing this, yet there is a significant downside in that the physician would be taking on all of the administrative costs and risks involved of billing and collecting, (e.g. working denials, billing patients). As I see it, your physician would be taking on a financial risk that has no potential to offer any rewards in return.
Thank you for your detailed answer. I will use this as my argument because I really don't see any advantage to this.
 
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