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stlbill511

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A new outside lab rep from North Carolina came into our office today. We are in Missouri. He states that we can bill out under the doctors NPI with POS 81 for outside lab 80104 and 19 other codes supposedly, and get reimbursed 500-750.00 for our UA tests. The lab will then bill the doctor $250.00. Is this legal to do? I am very skeptical of this, putting the doctors NPI in a place of service that he has never been to and will never be at. I told the rep this and he said this is all legal to do, but I know reps will tell you anything to get your business.

Thank you for any advice on this situation

Caroline Chafin, CPC
 
I think there is a way to do this - you can bill as 'purchased' services and/or use the box 20 on the 1500 form to indicate outside lab. But lab services are tricky and heavily scrutinized these days due to the anti-kickback laws, so I'd recommend running any arrangement by your lawyers before moving forward.
 
This reminds me of a lab that used to bill for quantative analysis on nearly every single drug class imaginable even after patient tested negative already and has tested negative for years charging nearly $1000 for a drug screen that should cost $100 max. The ordering physicans are none the wiser since they don't see the claims submitted. I cant seem to figure out why this lab cant bill the services directly with their own information like every other lab.

As mentioned above by genenut, id be worried the insurance company or Medicare comes after you if they find something wrong since you are the ones reporting the claims

I looked up CPT 80104 and it was deleted last year when they the drug screen codes were redone, so if that come from the rep, that may be a good clue you may have an issue right there
 
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They said it is direct billing. They told me that I put the physicians npi in box 33 and in box 32 the place of service is 81. They said we do not bill out to Medicare, just the commercial payors. They do the billing for Medicare. This does not sound right. They said that box 32 tells the insurance that it is an outside lab and I told them that Box 32 tells the insurance that the service was performed at that place. I am thinking it is fraud because the doctor is not performing the services at the lab. I told the doctor not to sign any contracts because I don't think this is legal. I am going to look up the direct billing.

Thanks for all the advice.

Caroline
 
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