General Category > General Questions
pass through billing
best biller:
thanks so much
PMRNC:
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.
slsandov:
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:
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.
timothyhadl:
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