Wiki The Ins and Outs of Laboratory Billing

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annawade13

annawade13

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I have a new endocrinology client who does a lot of labwork. I'm given to understand that some insurance companies, namely the government plans, require CLIA certification and since this provider doesn't have it, the lab who provides the services bills the insurance company directly. However, some insurance companies have not adopted this guideline, and those are the claims I am responsible to bill. I need help finding a published list of insurance companies that do/do not follow Medicare guidelines regarding CLIA certification. Can anyone direct me? Or is it plan/region specific and will I need to contact my provider rep for each payer?

Thanks so much for any help!
 
:eek: Hello, I am not aware of any listing of companies that don't require the CLIA cert, but it is a federal law that the provider be certified to bill certain labs. So if the provider does not have one, I would suggest you pass that information along. Just because the insurance company does not require it, does not mean that they should not have it. The law is called the "Clinical Laboratory Improvement Amendments (CLIA). It is enforced by CMS, FDA and Department of Health. Hope this helps.

Tina
 
More links to research for CLIA answers

Here are some links for you to look at regarding CLIA.

FDA link to a listing of “waived” analyte tests that are used in laboratory test systems.
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/analyteswaived.cfm


Department of Health and Human Services Booklet on CLIA:
http://www.cms.gov/Outreach-and-Edu...rk-MLN/MLNProducts/Downloads/CLIABrochure.pdf


A CMS/CDC booklet on CLIA requirements and info.

Link: http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/HowObtainCLIACertificate.pdf
 
Thanks, Airart. These helped a lot. It turns out this provider does have a CLIA cert but I think it's the waiver only; therefore he uses an outside lab to perform all complex tests. I would think it would be best for the lab to bill all the payers directly, but my practice manager assures me it's aboveboard for the laboratory to invoice the provider for these complex tests when the patient has a commercial plan and to let the provider bill the commercial plan directly. I wonder if anyone else has a provider that does this? I'm still stuck trying to figure out how to avoid CLIA denials, especially if a government plan is secondary.

Thanks,
 
Ins and Outs of Lab Billing

It could be that the lab is not in-network with alot of the commercial plans and doesn't want the hassle of getting credentialed with them. there are alot of independent labs who are contracting with physicians for these types of services. Helps out on the reimbursement side of things by just billing the doctor for the services used verses fighting the insurance companies and patients.

Plus, there are preferred labs that commercial payers use that force the patient to make sure the labs are being done through that particular one or they have to pay more out of pocket. :cool:
 
You could also contact your lab representative. When your lab was set up, they should have advised in which payers they were associated with and most of them (if they know there job) can advise you of which labs will pay you directly. BCBS of any state will allow you to bill them directly. You could also do a trial and error with payers. If they pay you? Great. If not just write it off and don't bill them anymore. (There is no cost to your office)

Medicare does not allow unless they are clia waived and actually performed in the office. If they are not performed in office, you can't bill for them.
 
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