BILLING 101W. Scott Campbell, Ph.D, MBALabpoint, LLC

Laboratory Services• Types of laboratory services

• Human Clinical

• Environmental

• Water

Human Clinical Process Overview

Patient Encounter

Obtain specimen

Process specimen

Get Paid

Payment Sources• Grants /State Funding (becoming limited)

• Monthly Invoicing• Very common• Pertains to human clinical, environmental, water

• Third party, insurance billing• Human clinical• Topic for today

Insurance Payment Process• Send bill for services and get paid, right?

• Not so fast…

• Insurance companies have a well-oiled process

• sPHL’s need to know the “rules of the road” to bill insco’sand get paid

Key Points to Understand• Required Information needed to bill 3rd parties

• Patient demographic information• Insurance information• Service and diagnostic codes (CPT/ICD)

• Required Policies, Processes• Tax ID, Provider ID’s, Facility ID• Legislative authority (3rd parties, individual tax payers)• Contracts with 3rd Party payers

• Required Infrastructure• Systems• Staff

Start at the Beginning

Patient Encounter

Information to capture at time of service:•Name, address, DOB

•Insurance information – Company, Member ID, Group ID, Relationship to insured

•Guarantor information – address

Forms to get signed:•Permission to bill insurance

•HIPAA release/policy

•Medicare billing forms

Clinical Information to Capture

Obtain specimen

Clinical Information Needed:•Reason for the test

•Indicated by Physician/Other provider

•ICD-9 code (Insurance Company Will NOT pay without this code)

•Ask at Order Entry Information (AOE)•Familiar to most labs

•Example: specimen source

Information to Capture in the Lab

Process Specimen

Information Needed from Specimen Processing:

• Lab Services Provided put into CPT code

• Not necessarily a one – to – one correlation between lab processes and CPT codes.

• Billing codes sent to Revenue Cycle System

• Results back to patient and clinician

Send Bill…Get Paid…Right?

Patient Encounter

Obtain specimen

Process specimen

Get Paid

Now comes the hard part…You need Betty the Biller

How does this get done?• Lab Services to Reimbursement

• Lab codes to CPT codes• CPT – current procedural terminology, 5-digit codes• Not a one-to-one between CPT and bench tests• The only codes acknowledged by 3rd party payers ( exception: HCPCS)

• Diagnostic codes• ICD-9 (Soon ICD-10); 3 to 5 character alpha numeric code• Tells the reason for the lab test

Example - STD• Gonorrhea/Chlamydia Test

• Local Code (STDSW)

• CPT Codes (two are required)• 87491: Chlamydia trachomatis, amplified probe technique• 87591: Neisseria gonnorrhoeae, amplified probe technique

• Diagnostic code• V01.6: Contact with or exposure to venereal disease

Example – Lead Screen• Lead Screening Test

• Local Code (LEAD)

• CPT Codes (one is required)• 83655: Lead Screening

• Diagnostic code• V15.86: Personal history of contact with and (suspected) exposure

to lead

Revenue Cycle Management Systems• Interacts with the Laboratory Information System

• Stores patient billing information

• Stores services rendered per encounter

• Formats/Sends Insurance Claims

• Patient-based billing

• Accounting for entire payment cycle

Insurance Claims• Insurance Claims

• CMS 1500 (Professional Services)• UB04 (Institutional)• Electronic Versions (x12.835)

• Claim formats – “Clean” Claims• Complete information – patient, insurance, services• Provider and Facility Codes• Formatted per third-party payer specifications

Insurance Payments• Clean claims processed; others? (Black Hole)

• Insurance claims paid per patient’s policy• Copayments, Deductibles• Covered/not covered services• Contractual payments vs. Charge

• Secondary and tertiary coverage

Patient Payments• Patients often must pay a portion of the bill

• You are required to attempt collection of the patient portion of the bill• Kick-back regulations• Indigence

The “New” Process

Patient Encounter

Obtain specimen

Process specimen

Get Paid

Third Party Billing

Approaches to the “New” Process• In-house personnel

• Billing Services (MSO – Management Service Organization)

• Partnering• Hospitals• FQHC (Federally Qualified Health Centers)• Other Labs – Reference or SPHL

Where to Get Help• APHL/Labpoint

• Visit website:

http://training.labpoint.com/course/billing-essentials/

• Series of informational videos from subject matter experts for various elements of the billing cycle

• Complete a “Needs Assessment Form” and a subject matter expert will contact you

Thank you