Billing Question

[weaseldom]

Some questions arose yesterday in a meeting we were having and I'm not quite sure where to seek the answers ~ anyone have any knowledge on this?

Scenario: Patient lives in State X (say Florida) and has health insurance there. The patient has a biopsy performed in Florida. The biopsy is then sent to an out-of-state lab in 'state Y' (say Mississippi) for processing and pathologist's interpretation (i.e. both the technical and professional activities are performed in Mississippi).

- Is the insurance company billed under Mississippi reimbursement rates for the technical and professional components OR are they billed under the state rates from which the patient lives/ the biopsy was performed?

Would the answer change if that patient is a medicare enrollee?

Would the answer change if the patient has private insurance that IS represented in both States X and Y?

Would the answer change if that patient has private insurance that IS NOT represented in State Y?

Thanks!

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[pathstudent]

Some questions arose yesterday in a meeting we were having and I'm not quite sure where to seek the answers ~ anyone have any knowledge on this?

Scenario: Patient lives in State X (say Florida) and has health insurance there. The patient has a biopsy performed in Florida. The biopsy is then sent to an out-of-state lab in 'state Y' (say Mississippi) for processing and pathologist's interpretation (i.e. both the technical and professional activities are performed in Mississippi).

- Is the insurance company billed under Mississippi reimbursement rates for the technical and professional components OR are they billed under the state rates from which the patient lives/ the biopsy was performed?

Would the answer change if that patient is a medicare enrollee?

Would the answer change if the patient has private insurance that IS represented in both States X and Y?

Would the answer change if that patient has private insurance that IS NOT represented in State Y?

Thanks!

This is just a guess.

If the path lab in Mississippi is billing a government insurance they get reimbursed medicare rates in Mississippi.

If the path lab is billing private insurance, they have a contract and get paid whatever it says in their contract.

There could also be a "client-billing" arrangement between the doc in florida and the lab in Mississippi in which case the doc in florida gets paid by the insurance company and then he essentially splits that amount with the lab in Mississippi. You can't do that with government patients because it is unethical, but it is common practice in much of the US.

 

[yaah]

If the Missisippi lab is interpreting and reporting specimens from Florida, I believe they need to have a florida license. Don't think you can accept out of state specimens if you aren't licensed. I may be wrong on this since this is not my field of expertise though. And I believe you bill wherever the origin of the specimen is because that's where the patient is. For govt insurance the rules may be different, I don't know. But yes, as said above, there may be other arrangements I would think.

 

[LADoc00]

Client billing is illegal in California, other states as well. FYI

The tests are billed where they are performed, in this case they would be billed under the locality code for CMS in MS. This is why so many reference labs are performed in Orange County CA, because it has the highest reimbursements of any place in the US.

The practitioner would only need a FL license IF some component of the process occurs in FL. If the specimen is merely jarred and sent out, he would not need a state specific license UNLESS the state Medicaid equivalent requires it.

The private insurance question is immaterial. Insurance products may have a select list of preferred providers but arent generally limited to a geographic area.

All of the above applies to the continental US and I see you are from PR. YMMV.

 

[WEBB PINKERTON]

Are you sure they don't need a Florida license? I though you had to have a Florida license, even if you are in another state, or you are SOL. I have a relative down there who is director of a huge laboratory.

 

[LADoc00]

Are you sure they don't need a Florida license? I though you had to have a Florida license, even if you are in another state, or you are SOL. I have a relative down there who is director of a huge laboratory.

As I said unless the state Medicaid program has some type of unique restriction OR if some component of the process is occurring in state, like a portion of the TC or if it is some type of client bill situation.

Think about it, if there was a blanket restriction on cases being sent out of state you could never get a referral from an out of state academic center and no offense to FL academic pathologists but they don't have a reputation in the caliber of Mayo/Stanford/BHW/Hopkins...

 

[Torsed]

No they (the lab in MS) may not need a Florida license. I've investigated this myself as it came up with client billing practices in my state (specifically surgeons sending biopsies to another lab in a separate state).

I have emailed State Boards and while some require licensure, there are MANY southern states at least that do not require the reading pathologist to have a license in the patient's (say Florida patient's) state. As long as the reading pathologist has a license somewhere in US they will let this ride.

The head of the state board pretty much told me to F off about the issue and not bother him/her again.

 

[turtle1966]

As I said unless the state Medicaid program has some type of unique restriction OR if some component of the process is occurring in state, like a portion of the TC or if it is some type of client bill situation.

Think about it, if there was a blanket restriction on cases being sent out of state you could never get a referral from an out of state academic center and no offense to FL academic pathologists but they don't have a reputation in the caliber of Mayo/Stanford/BHW/Hopkins...

Medical boards, insurance payers, your liability insurance company and plaintiff lawyers are the interested parties on this issue. Can you think of any willing to voluntarily and in writing give up their grip?

Dermatopaths in national labs not uncommonly have over 10 state licenses for those reasons. California Board absolutely requires CA license in the above circumstance. Most make an exception for consults though.