Pathology/Lab Coding Alert

Get disclosures in place before Jan. 1 deadline.

“Health insurance should offer patients peace of mind that they won’t be saddled with unexpected costs. The Biden-Harris Administration remains committed to ensuring transparency and affordable care, and with this rule, Americans will get the assurance of no surprises,” said Xavier Becerra, Secretary of Health and Human Services (HHS).

Read on to learn how the rule might impact your lab and what you can do to prepare.

Master the Basics

The legislation says that emergency care must be billed at in-network rates, without prior authorization, for facilities, as well as the healthcare providers delivering the services.

But even care that isn’t emergent will have new obligations you need to know. The interim final rule also says that nonemergency services provided by out-of-network providers must be treated like in-network services unless the insured individual is provided notice and gives consent, says Lisa A. Lucido at Hall Render, in online analysis of the interim final rule.

The rule encompasses services like laboratory, imaging, and telemedicine, as well as equipment and devices — regardless of whether the provider furnishing the services is present at the facility, she says.

Air ambulances are also facing tighter payment regulation, says Catherine Howden, director of CMS News and Media Group, quoting a 2019 study by the Government Accountability Office (GAO) that found that the median price charged by air ambulances was nearly $40,000, and 70 percent of these transports were considered out of network for patients.

Constrain Pathology/Laboratory Balance Billing

Although the final rule allows balance billing in certain cases of non-emergency care if the patient receives appropriate notice and consent, pathologists and laboratories may be caught in the middle.

The rule states, “The notice and consent exception does not apply to ancillary services … related to emergency medicine, [including]… pathology … whether provided by a physician or non-physician practitioner; … [or] diagnostic services, including … laboratory services.”

The reason for excluding ancillary services is that they are generally not “shoppable” by patients, and account for some of the highest rates of out-of-network charges.

Does law apply: Labs and pathologists might even have a hard time discerning if the No Surprises Act applies to a specific case. You may not have knowledge of whether the test order is for an emergency patient, or for a non-emergency in-network hospital patient for whom your lab is out of network. For a pathology service or clinical diagnostic test that isn’t addressed under the law, balance billing is still acceptable.