OPPORTUNITY BIG REIMBURSEMENT FROM MEDICARE -$2,100

[diagnostico]

A laboratory contacted me and asked would I market their new DNA/Genetics Test Panel Cytochrome P450 that reimburses well by Medicare. he will charge me $50 to process each sample and then my company can bill Medicare for the lab cpt codes for up to $2,100. Is this legal? How can my company legally bill Medicare or WC or PIP when we don't actually have the lab but we do get the patient approval, lab approval to bill the insurance company. How can we get the checks to come in in our company name and not the labs name? I have seen a company do this exact same thing and get checks from the insurance companies in their company name.
Your help is appreciated.

[RichardP]

With any test, be it lab or radiology or whatever, there is the technical component and the professional component.  Technical = whoever performed the lab test or shot the x-ray or whatever.  Professional = whoever interpreted the results of those tests.  Do you do either of those two things.  If not, you have no basis from which to request payment for your services.

The above paragraph is a separate issue from the fact that you can be designated as the receiver of payments from Medicare and other Carriers - as a fiduciary for the end recipient.  That is, you can collect payment on behalf of a doctor, but you must pass that payment through to the doctor.

The distinction is between earning the money versus collecting the money on behalf of the one who earned it.  If you do not either perform the tests or interpret them, you cannot be paid as the earner.

If you are a billing company, you can bill on behalf of the doctor (using his NPI number) and you can bill on behalf of the lab (using their NPI number) and payment will be sent either to the doctor or the lab.  I know it is possible to receive payment in the name of your billing company - on behalf of your clients - but there are registration requirements and other hoops to jump through with Medicare and the insurance carriers in order to make this happen.  But keep in mind that you are still only passing money through to your clients - the money would not be paid to you as the earner.  You can't keep the money.

[PMRNC]

CMS has pretty tight rules on reassignment... aside from that you will absolutely NEED a surety bond if you collect monies.  You can also look into a lock box as well.

[diagnostico]

RichardP,
That information was very insightful. You know your stuff.
My company, however has contracted the lab to do the work for us. They are like a subcontactor for us. The doctor is sending the samples to a lab hired by us to process the samples.shouldn't that. Matter?

[RichardP]

I just added the last paragraph to my post, in case you haven't seen it yet.

[diagnostico]

Thanks for all of your feedback PMRC.
Will the lockbox be a substitute for the surety bond?
Is there a legal loophole around the "reassignment" issue?

[diagnostico]

Couldn't I just contract the lab out to do the sample processing and bill the insurance company as if I were the lab? C

[RichardP]

The doctor is sending the samples to a lab hired by us to process the samples.shouldn't that. Matter?

It does matter.  But this is the point where you need a health-care attorney who is very familar with both the Federal and your state laws against self-dealing.  You are still facing the technical and professional issue though.  If you are not certified as a lab, you cannot claim the technical component - because you did not do the work.

[Edit]

Couldn't I just contract the lab out to do the sample processing and bill the insurance company as if I were the lab?

No.  Your healthcare attorney will tell you why not - but bottom line, you can't claim to have done the work when someone else actually did it.  Well, you can - until you get caught and sent to jail.

[PMRNC]

I was going to say exactly what Richard said, these are legal questions best answered by both YOUR attorney and the lab's attorney, there are many many factors to consider, I cannot see how you could just bill the carriers as a non medical supplier.  But again, these really are some very heavy legal issues you want to discuss on both sides to cover both of you.

[RichardP]

diagnostico - a lab cannot get paid by Medicare unless it has a CLIA number.  Medicare has mapped a given CLIA number to the Type 2 (who gets paid) NPI number of the lab owner.  Further, they then map the CLIA and NPI numbers to the address where payment should be sent.  Medicare will not issue payment unless the CLIA number and NPI number on the HCFA form match exactly what they have in their system.  Given that they match, they will send payment only to the owner of the NPI number on file.

For you to receive payment, you must break the relationship outlined in the above paragraph.  It is possible to do this, but you have some significant hoops to jump through in order to do it successfully.  That is why you need a healthcare attorney who knows his/her stuff.  If you don't do it correctly, you won't break the relationship outlined in the above paragraph, and payment will continue to be sent to the lab.

The rules for non-Medicare carriers are probably looser than Medicare's.  But the carriers tend to mimic what Medicare does.  So you probably need to do something similar with them as well.