Test billed by another lab

rbordes

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I recently started working at a Path Lab and for UHC, BCBS, and Aetna, I was asked to stamp the Path reports with a certain stamp "ABC Pathologists", for only those three payers and sent to this other company to bill. I asked why and was told, we were not In Network, and where we are sending them to be billed has a great contract and gets a high reimbursement, so we send those to them to bill, and we client bill them a flat fee. My question is, isn't that "redirecting claims to be paid". I asked about all the other payers, and they said, no we just bill them and if we are OON we just write them off. Something does not sit right with me on this.... because some of our Dr. have become in network and we still send to them to this other company, because we get more $$ by doing this.
 

rbordes

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Correct! That is exactly what I thought! Ok, I know what is needed then... thanks!
 

SharonCollachi

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Correct! That is exactly what I thought! Ok, I know what is needed then... thanks!

I'm trying to remember... I saw something online or on tv about a tiny town having thousands and thousands of lab tests run thru there, far more than the number of residents. I can't recall all of the specifics, but I was thinking that it was shut down but that may be an avenue to research.
 

thranowski

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So this other lab is only doing the billing and not performing any service? Sounds like a big ol' case of fraud to me.

Wow yes. If/When insurance finds out, that place is going to shut down. All that money is going to be owed back and they're going to be fined out the yin yang, and iirc they can be fined PER claim. I wouldn't want to be them.
 

SharonCollachi

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How is that fruad if they use a 90 modifier and put the name of the lab running the test in box 32?

Because this situation doesn't fit modifier 90.

Modifier 90​


Reference (Outside) Laboratory

Instructions​

Sometimes a clinical diagnostic independent lab, place of service (POS) 81, refers a specimen to another lab for testing, where a modifier 90 is appended.

Correct Use​

  • Outside laboratory performs procedure, unrelated to treating/reporting physician
    • In most cases, lab furnishing the service would bill the claim
  • Possible for one lab to bill service performed by another lab
    • Referring = referring specimen to another laboratory for testing
    • Reference = lab that receives specimen from another lab and performs one or more tests on such specimen
  • Must append modifier 90 to referred laboratory test code
    • Item 20 mark "Yes" = outside lab
    • Purchase price must be reflected under charges
    • Complete item 32 with NPI, name and address where performed
  • Appropriate modifier 90 claims include two different Clinical Lab Improvement Amendment (CLIA) numbers
    • Reflect billing provider information
    • Laboratory where services were performed (reference lab)
  • Bill claims with modifier 90 and without modifier 90 separately
  • If no purchased services, leave item 20 blank

 
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I see, so if a labs client orders a blood test for example, and our lab only offers toxicology testing, we could then, send it out to a reference lab, then bill it out with a 90 modifier and the reference lab. In this specfic case, this lab CAN run the test and ARE but sending it to another lab to bill it for them?
 
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