The prime task that laboratories take care of is examining the chemical and other specimens collected from a human body. This examination helps in diagnosis, treatment and the prevention of health conditions. Last tests are usually ordered by physicians for apt determination and better diagnosis. The largest payer in the US that takes care of lab test expenses is Medicare. Claims containing information about the type of tests carried out, details of lab provider, ordering physician, and the beneficiary.
According to a study around 50%
of beneficiaries registered under the Medicare program, availed lab services at
least one time in a year.
With a large crowd availing lab
services every year, it becomes crucial for labs to stay current with the
compliance and Laboratory billing guidelines. There have not been many changes in billing
rules except for the compliance guidance that was updated back in August 1998.
And, to our surprise or we shall it bad luck for lab owners, the section
listing risks associated with lab billing remains untouched. It has not been
changed since 1998 – another reason to worry for lab owners. It is important to
note that any mistakes in billing or non-compliance to guidelines will lead to denials
or partial reimbursements. Worst case scenario- it can attract legal
proceedings as well.
Some of the very common reasons
for issues faced by lab owners while billing can be highlighted as:
• Insufficient documentation and
failure to prove medical necessity.
• Lack of physician order for lab
tests.
• No reviews before or after
claims adjudication.
• Not providing lab test results
to patients.
• Improper use of Modifiers.
• Inaccurate billing and coding
for drug tests.
• Over-coding or Under-coding.
• Not keeping up with the claim
submission deadlines.
• No awareness regarding changes
to the fee schedule.
Issues faced while billing
A majority of lab billing issues
arise due to non-compliance and committing billing errors. Some of these issues
can be explained as:
• Incomplete Payment - When lab owners bill medically
unnecessary services or are not able to prove the medical necessity for the
billed services, insurance does not pay according to the contract resulting in
incomplete payments. Make sure to include proper documentation to support the
services billed.
• Missing Documentation - Claims can be denied if the
insurance does not receive the RX form or the ordering form signed by the
ordering doctor. In this case, the services may also be classified as “Not
medically necessary”. Therefore, it is
important to include order and intent form while billing for laboratory
services. Other documentation must also be complete and should mention complete
details about the tests so as to allow verification.
• Billing Inter-Related Tests - Proper care should be taken while
billing for inpatient claims. If you are billing inpatient services along with
the surgical ones, make sure to include supporting documentation for inpatient
services or, it may cause a dual denial situation. As an inpatient surgical
claim denied for medical necessity could result in a denial of Medicare Part-B
services.
The solution
Laboratory billing services
require a whole different skill set. The best way to alleviate issues
associated with lab billing is by outsourcing laboratory billing services to a
trusted and experienced partner.
Outsourcing makes handling out of
network claims, and managing information much easier. Their knowledge in
billing management and the laws applicable in each state, understanding of the
complex payer policies and being able to stay current with the constantly
changing rules is what really makes a difference.
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