Author Topic: pass through billing  (Read 16722 times)

best biller

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pass through billing
« on: February 26, 2013, 10:40:58 AM »
is anyone familiar with what pass through billing is?

PMRNC

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Re: pass through billing
« Reply #1 on: February 26, 2013, 12:30:31 PM »
Pass-through billing is when the ordering provider requests and bills for a service, but the service is not performed by the ordering provider.

Medicare prohibits pass through billing, so do most other carriers, I know BCBS does not allow it
Linda Walker
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One Stop Resources, Education and Networking for Medical Billers
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best biller

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Re: pass through billing
« Reply #2 on: February 26, 2013, 02:40:08 PM »
the provider who asked me about pass through billing has two locations. she wants to do this billing for the location in Connecticut. is it allowed to do in Connecticut?

PMRNC

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Re: pass through billing
« Reply #3 on: February 26, 2013, 05:02:43 PM »
There are many legal issues with pass through billing which is probably why it's prohibited by Medicare, Because of stark and Anti-kickback rules, I would have your provider consult with an appropriate attorney for the answer on this.
Linda Walker
Practice Managers Resource & Networking Community
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best biller

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Re: pass through billing
« Reply #4 on: February 26, 2013, 07:01:47 PM »
This is what that doctor asked me,

Can you please tell me if you know how to do,, pass through billing "
for the laboratory tests I am doing in my Connecticut office?

Any help would be greatly appreciated.

RichardP

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Re: pass through billing
« Reply #5 on: February 27, 2013, 12:01:48 AM »
best biller - This is probably overkill, but here goes.

An example of Pass-Through Billing would be if your physician drew blood and sent it to an outside, commercial (non POL) laboratory.  The laboratory would do the work, and bill the doctor for the work.  The doctor would pay the commercial lab for the work they did.  The doctor would then submit a bill to the patient's insurance for the lab work done by the outside commercial laboratory.  In other words, your client would buy the services from the lab at maybe a discounted price, would mark up the price he charges for these labs, and would then pass that increased charge either to the patient or the patient's insurance company.  (You could substitute independent pathologist for commercial laboratory in this paragraph)  Your client probably wants to know if you know how to handle all parts of this transaction, billing-wise.  See this link:

http://www.jdsupra.com/post/fileServer.aspx?fName=f4f0c0ac-a080-4fa5-8206-7284bc03a7b1.pdf

It is my understanding that the only labs that a doctor can bill Medicare for are those labs he does personally in his own Physician Office Lab (POL), using his own CLIA number and NPI number(s).  A lab for a doctors group would bill under the CLIA and NPI numbers of the doctors group.  It is my understanding that any other lab must have its own CLIA number and NPI number(s), and must bill Medicare themselves for all lab work done.  It is my understanding that a doctor may not bill for labs sent out to a commercial laboratory.  The commercial laboratory must do the billing, under their own numbers.  I understand that the concept of waived status complicates these relationships a bit, but I think I have laid out the accepted / expected billing scenario for the non-waived billing situations.

Note that Medicare allows pass-through billing for certain drugs and biologicals.  Don't confuse that issue with pass-through billing for labs.

Here is a blurb from United Healthcare about Pass-through billing:

If you are a physician, practitioner or medical group, you must only bill for services that you or your staff perform. Passthrough billing is not permitted and may not be billed to our Customers. For laboratory services, you will only be reimbursed for the services for which you are certified through the Federal Clinical Laboratory Improvement Amendments (CLIA) to perform, and you must not bill our Customers for any laboratory services for which you lack the applicable CLIA certification; however, this requirement does not apply to laboratory services rendered by physicians, practitioners or medical groups in office settings that have been granted “waived” status under CLIA.

From here, Page 48 / 54:  https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/2011_UHC_Administrative_Guide.pdf

best biller - is there any chance your client is using the wrong words, and is actually asking you about billing for the professional component and/or the technical component of lab work?

3. Purchased service billing. Medicare allows the physician to purchase the technical component of the pathology services from an outside reference laboratory. The purchasing of the technical component is only allowed if the practice reads its own slides. In this scenario, there are two options:
        a. The technical component is billed by the laboratory and the practice only bills for the professional component.
        b. The technical component is billed by the physician who purchases it. In this scenario, the physician can bill Medicare only the exact amount charged to the practice for the technical component by the outside lab. In other words, if the laboratory charges $10 for the slide prep, then the practice can only bill Medicare $10 for the technical component.
            • No mark-ups are allowed.
            •The technical component must be billed on a separate claim form. It can’t be billed on the same claim form that contains the billing for the professional component.
            • No global billing is allowed if either component is purchased. Global billing refers to billing the pathology service with no modifiers.

4. Global billing. In this scenario, the practice has its own in-house laboratory, a High-Complexity CLIA certification, and not only employs physicians who read the slides, they also make their own slides. No portion of the pathology service is purchased.

Billing is done directly from the practice and no modifiers are needed when billing for pathology services.


From Billing Scenarios, here:  http://www.gaderm.org/InfoForum.htm
« Last Edit: February 27, 2013, 12:40:23 AM by RichardP »

elizabethberger

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Re: pass through billing
« Reply #6 on: February 27, 2013, 03:48:18 AM »
Hey, I was looking for information like this. Thankyou for sharing this-Richard and Hero Member

RichardP

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Re: pass through billing
« Reply #7 on: February 27, 2013, 12:42:39 PM »
You are welcome.  Glad you found the info useful.

best biller

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Re: pass through billing
« Reply #8 on: March 04, 2013, 10:06:29 AM »
My provider claims that pass through billing is legal in Connecticut, is anyone familiar with that?

RichardP

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Re: pass through billing
« Reply #9 on: March 04, 2013, 10:59:48 AM »
If you re-read my comment above, you will notice that the prohibition against pass-through billing is an insurance carrier issue - not a state regulation issue.  In that context, state regulations are not what make the difference.  So, being in Connecticut instead of in California won't be what makes the difference.  It will be whether the insurance carrier in Connecticut accepts pass-through billing.  Maybe they do - you would need to check with them.  But Medicare regulations don't change based on the state you are in.  For example, Medicare will not accept pass-through billing in Connecticut and reject pass-through billing in California.  The Medicare regulations are equally applied across all states.

best biller

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Re: pass through billing
« Reply #10 on: March 04, 2013, 11:46:39 AM »
thanks so much

PMRNC

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Re: pass through billing
« Reply #11 on: March 04, 2013, 01:06:38 PM »
From everything I'm reading there is a lot of legal considerations for pass through billing. Also it's not just Medicare but ALL govt sponsored health plans (Medicare, Medicaid, Tricare, etc)  I admit to not really knowing Much about the process.. however we did red flag pass through providers when I worked as a claims examiner. A red flag is not good. We seen a lot of red flags specifically in conjunction with laboratory billing.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

slsandov

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Re: pass through billing
« Reply #12 on: March 29, 2013, 02:45:06 PM »
can some one direct me, I was trying to search on CMS website and our Medicare carrier Novitas, where the regs are on pass through billing.  I know it is not allowed but want it in writing for my employer. thanks

RichardP

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Re: pass through billing
« Reply #13 on: March 29, 2013, 04:01:05 PM »
Medicare allows pass-through billing on some drugs, biologicals, and radiopharmaceuticals.  Search on the term pass-through (with the hyphen) at this link:

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c17.pdf

Pass-through billing on Medicare lab charges is a totally different animal.  Please carefully re-read the following paragraph I am copying from my response above.  Note the bolded sentence.  There does not need to be a separate prohibition by Medicare against pass-through billing for labs.  The bolded sentence serves as the necessary constraint.  A doctor may not bill Medicare for any labs except those he himself performs.  If your doctor has a physician office lab, s/he would have already been provided with this information in the process of getting the lab license.  If your doctor is still unsure of this logic, or if they are contemplating setting up their own lab, they should not proceed without the services of a health-care attorney.

It is my understanding that the only labs that a doctor can bill Medicare for are those labs he does personally in his own Physician Office Lab (POL), using his own CLIA number and NPI number(s).  A lab for a doctors group would bill under the CLIA and NPI numbers of the doctors group.  It is my understanding that any other lab must have its own CLIA number and NPI number(s), and must bill Medicare themselves for all lab work done.  It is my understanding that a doctor may not bill for labs sent out to a commercial laboratory.  The commercial laboratory must do the billing, under their own numbers.  I understand that the concept of waived status complicates these relationships a bit, but I think I have laid out the accepted / expected billing scenario for the non-waived billing situations.

Also, you might scroll up and re-read what I said about the professional component and the technical component for pathology work.  That is a slightly different animal from blood and urine testing, but it is important to know that it exists also.

(Added, for those who may not know.)  If a doctor wants to get paid by Medicare for doing lab work, he must register his lab with Medicare (this is true for any lab: POL; Group; Independent).  The doctor must give Medicare the CLIA number of his lab, and his Type 2 NPI number (who gets paid).  Medicare links that CLIA number to that NPI number in their computer.  When the doctor submits lab charges to Medicare, for payment from Medicare, the CMS Form must contain that CLIA number and that NPI number.  If they match what Medicare has on file, the claim is paid.  If those numbers don't match what Medicare has on file, the claim is denied.  Two points fall out from this paragraph:

1.  The doctor can charge Medicare whatever he wants to charge for the lab work.  But he is only going to get paid what Medicare is willing to give him.  And Medicare will dictate to the doctor what, if anything, the doctor can charge the patient for the lab work above what Medicare pays.

2.  The doctor could pay some other lab to actually do the work (a pass-through billing setup).  But for the doctor to make a profit, what he pays the other lab must be less than what Medicare will pay the doctor.  And when the doctor submits the charges to Medicare, with his CLIA Number on the CMS Form, he is certifying that it was the lab attached to that CLIA Number that did the work.  Since that is not a true statement in this instance, the doctor is opening himself up to serious charges of fraud if he ever gets caught.  Given that he cannot make any more money in this situation than he can if he did the work himself, there really is no point to doing this.

These two points serve as the constraints that keep honest doctors from doing laboratory pass-through billing on Medicare patients.  There does not need to be a Medicare regulation specifically prohibiting it.  There may be such a regulation, but it is redundant if it exists.  Remember that Medicare has on file, and connected to each other, the doctor's CLIA number and his Type 2 NPI Number.  Remember that these two numbers must be on any CMS form submitted to Medicare for payment of lab charges.  Any doctor who does pass-through lab billing on Medicare patients is commiting fraud - because he would be submitting to Medicare for payment under his CLIA Number work that was not done by the lab which the CLIA Number is attached to.

That last sentence makes sense to me, because I deal with this stuff.  If you are a newbie and that last sentence is not clear to you, let me know and I will try to rephrase it.
« Last Edit: March 29, 2013, 05:32:48 PM by RichardP »

timothyhadl

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Re: pass through billing
« Reply #14 on: May 08, 2013, 06:40:07 AM »
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