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Labs not covered/pt responsibility

  1. Default Labs not covered/pt responsibility
    Medical Coding Books
    Most of our patients are covered for lab work (urine testing, i work for a pain specialist) but there are a few who have gotten denials stating these tests are not a covered benefit, leaving them with a $220 bill for what they see as "just peeing in a cup" which doesn't seem fair. These tests are essential so we have to do them. Can we legally discount this amount?

  2. Thumbs up
    Is the provider in-network with the patient's plan? If so, make sure that this service is not considered to be bundled into the office visit. Some carriers do not consider this for separate payment. If not, then you may by all means discount this amount ,but of course you'll have to okay it with the provider first.
    Hope this helps!

  3. #3
    Location
    Columbia, MO
    Posts
    12,526
    Default
    what dx codes are you using for the drug tests?

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Default
    Quote Originally Posted by LuluBarr View Post
    Most of our patients are covered for lab work (urine testing, i work for a pain specialist) but there are a few who have gotten denials stating these tests are not a covered benefit, leaving them with a $220 bill for what they see as "just peeing in a cup" which doesn't seem fair. These tests are essential so we have to do them. Can we legally discount this amount?
    I agree w/Debra - it's likely the diagnosis causing the denial. "Not a covered benefit", is really not as specific as it sounds. What's not covered? Labs in general? This particular lab? Is it ever covered, or is it only not covered for this diagnosis? Under what circumstances would it be covered?
    Pull old billing records to see if the same payer has ever covered the service on a previous date. If you can find where it paid before (score!), ask them about it. "We billed this exact same procedure on DOS XX/XX/XX, and it paid without any problems. What's changed about the policy since then?"

    For non-covered charges, you can discount whatever you want. It's deductibles/copays/coinsurance that you've got to be careful about giving freebies on. And on a related note: if you have labs applying to deduct/copay, when they normally don't, make sure that they're being processed on the same claim as you E/M. If they aren't, have them reprocessed that way - many times, that makes the difference. Hope that helps!

  5. Default
    thanks guys this seems helpful. we use 305.90 for most of our tests but i will check with the physician and also the patients insurance to see if there are other options and how these are being processed.

  6. #6
    Default
    That makes sense - You're in the mental health section - that'll do it every time. If they're applicable, use V58.69 and/or V58.83 instead.

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