Pathology/Lab Coding Alert

Question: Our lab changed the type of kit we use to test for bilirubin in whole blood. The new test is much more expensive, and measures alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase, total bilirubin and urea levels. Now we're finding that the amount the insurer allows for a bilirubin test is well under our cost. If I bill the insurer, I am bound by our contract with them to write off the provider discounted amount. Can I just bypass billing the insurer and offer the patient the option of purchasing the test without insurance?

Missouri Subscriber

Answer: No, you cannot bypass billing the insurer and "offer" the patient the option to pay out-of-pocket. If you are contracted with the insurer, then you agreed to abide by the payer's fee schedule and accept that payment as payment in full. That is a contractual obligation.

You can't just bill the patient to get more money because you don't like what the insurer would pay. You would be violating your contract (which is fraud). Also, the patient would probably not be happy with the offer to pay for a test that her insurance covers. For now, you're stuck with the contractual payment.

Do this: To avoid these problems in the future, your lab should review the fee schedules set out in your payer contracts. When your contract is up for renewal, you should consider negotiating this code, and perhaps others, to see if the payer will increase the reimbursement to at least cover your costs.