Reference Laboratory (Send Out) Testing and Billing in a legitimate way

The increasing prevalence of chronic and infectious diseases has been creating a high demand for medical diagnostic and testing procedures. The rapid detection of diseases requires specialized laboratory testing instrument and skills. Outsourcing these critical diagnostic procedures to reference laboratories aid the healthcare practitioners to provide timely diagnosis and offer value-based care to patients. Thus, the rising prevalence of such infectious diseases, which require specialized laboratories for testing, has increased the need for outsourcing testing services to reference laboratories nationwide.

?Laboratories, Hospitals and physicians are often turned to an external reference or diagnostic laboratory to handle complex or rarely-utilized tests, as these types of labs have intentionally invested in the machinery and personnel to conduct them. These facilities often produce a more cost-effective and time efficient accessioning?process as opposed to doing it in-house. Additionally, some perfectly functional labs that already perform tests for a hospital or physician may be confronted with an ordered test which the laboratory is not suited to handle. This may then result in contracting a secondary reference lab to perform the test, though such activity may result in the problematic situation of dealing with who's responsible for the billing of the test and reporting of the results.

?Do you know what is the legitimate way to bill the referred laboratory testing?

?There are certain protocols you need to follow otherwise insurance carrier may recoup the payment at any stage when they determine tests were billed violating/ignoring the defined billing guidelines and standards.

?Sypore is helping providers to bill reference testing in a complaint way.

?Let’s walk you through!!!

?Medicare defines a referred clinical diagnostic laboratory service/test as a service performed by one laboratory at the request of another laboratory. “Referring laboratory” is defined as the laboratory that refers a specimen to another laboratory for testing. “Reference laboratory” is defined as the laboratory that receives a specimen from another laboratory and that performs one or more tests on such specimen.

?Policy: Although Medicare payment may generally be made to an independent clinical laboratory only for those tests that it performs, payment may also be made to a laboratory for a test that is on the clinical laboratory fee schedule

that it has referred to another laboratory, provided the referring laboratory meets one of the following three conditions:

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- It is located in, or is part of, a rural hospital;

- It is wholly-owned by the reference laboratory; or both it and the reference laboratory are wholly-owned subsidiaries of the same entity; or

- It refers no more than thirty (30) percent of the clinical laboratory tests annually to other laboratories, (not including referrals made under the wholly-owned proviso, above).

?Examples of 30 Percent Exception:

(1) - A laboratory receives requests for 200 tests, performs 139 tests, and refers 61 tests to a non-related laboratory. All tests referred to a non-related laboratory are counted. Thus, 30.5 percent (61/200) of the tests are considered tests referred to a non-related laboratory and, since this exceeds the 30 percent standard, the referring laboratory may not bill for any Medicare beneficiary laboratory tests referred to a non-related laboratory.

(2) - A laboratory receives requests for 200 tests, performs 139 tests and refers 15 to a related laboratory and 46 to a non-related laboratory. Only 23 percent of the tests were referred to non-related laboratories. Since this is less than 30 percent, the referring laboratory may bill for all tests.

?NOTE: Only one laboratory may bill for a referred laboratory service. It is the responsibility of the referring laboratory to ensure that the reference laboratory does not bill Medicare for the referred service when the referring laboratory does so (or intends to do so). In the event the reference laboratory bills or intends to bill Medicare, the referring laboratory may not do so. The Medicare allowed amount for a referred test is based on the fee schedule in effect where the test was performed. For services that are carrier priced, the reimbursement amount will be based upon the price developed by the carrier processing the claim.

?The billing laboratory, whether it is the referring laboratory or the reference laboratory, must submit its claim to the carrier in which it is enrolled by reason of having a physical presence.

When the billing laboratory is the referring laboratory it must:

?- Identify the referred service as such by use of appropriate modifier.

- Identify the reference laboratory by specifying its CLIA number and address (i.e.,?the address where the test was actually performed) in the right fields.

?Be advised that there are different instructions set by the Medicare for paper and electronic claim submissions. Referring laboratory should be aware of when to submit a separate claim for referred tests and when to include referred tests on the same claim. Sypore takes care of all the billing standards and protocols for you so you may have peace of mind and pay all your attention to the growth of your business.

We are made its mark all across the country providing End-to-End RCM services to all kind of Laboratories, Physicians (PCP & Specialists), Skilled Nursing Facilities, DME providers and Urgent Care Center.

We are not just another billing company, our full proof and re-engineered processes, dynamic and proactive approach and highly qualified hands behind the services protect every penny of your business. We provides the care to your business you deserve. In our business you are not just a number, our clients are important to us regardless of turnover or discipline. Our personalized service fulfils all your needs and enquiries. We sees your services as $ and paves their way to your bank account. We keeps the relationships of provider healthy & pleasant with patient, insurance and other third parties which is the guarantee of revenue inflow.

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