General Category > General Questions
pass through billing
RichardP:
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
elizabethberger:
Hey, I was looking for information like this. Thankyou for sharing this-Richard and Hero Member
RichardP:
You are welcome. Glad you found the info useful.
best biller:
My provider claims that pass through billing is legal in Connecticut, is anyone familiar with that?
RichardP:
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.
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