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Fam Pract Manag. 2000 Jun;7(6):70.

Billing for lab tests

Q

Our six-person family practice is considering signing a contract with a lab company that would enable us to send specimens obtained in our office to the lab company through its courier, bill the insurance company for the lab test and receive reimbursement. This seems like a simple process. Am I missing something?

I don't believe you are missing anything. Many commercial insurers allow physician practices to bill for diagnostic lab tests that the practices purchase from reference labs. In fact, CPT has a modifier (–90) that practices can attach to the procedure code to indicate that a reference lab was used.

However, Medicare won't reimburse a practice for such tests; the reference lab must submit its own claim and be reimbursed directly. You might want to confirm that there are no state laws, akin to the Medicare provision, that would affect your ability to do this with Medicaid or commercial patients.

Backdating referral authorizations

Q

As a family physician, I am continually asked to backdate my signature for authorization of specialty treatment that has already occurred. Is it illegal to do this, and if so, how can I stop doing it without alienating my patients and their other physicians?

Even though your motives are pure and the goal is to benefit your patients, backdating a chart entry is usually viewed by the licensing authorities as failing to maintain an accurate record. It can also be seen as insurance fraud. From a liability standpoint, the record would contain proof that you had contact with the patient on a date when in fact you had no interaction. As a result, your credibility and that of the chart could be compromised.

Both your patients and the referral specialists have to comply with the requirements of the managed care contract. Since patient education begins in your office, consider posting a sign that reminds managed care patients that they must obtain your authorization prior to seeking care from other specialists. Also, let them know that managed care organizations will not cover care provided by other specialists unless a referral has been made in advance. You and your staff should also reiterate this information in person.

The staff members at the other specialists' offices are well aware of this requirement and should be asking about referral forms when the patient calls for an appointment. Finally, make a courtesy call to those offices that haven't yet adopted this procedure to suggest that they do so.

Considering ultrasound?

Q

I'm considering doing ultrasound in my office and would like to know about all the pros and cons. Can you help?

Any relatively easy diagnostic procedure that can be safely performed in the office, especially ultrasound, can have a positive financial effect on a practice. However, there are a few things to consider before deciding whether ultrasound will be a worthwhile addition to your office practice.

How often will you be reimbursed for the procedure? If you contract with a lot of managed care plans, you'll need to check each contract to determine whether you can even be reimbursed for this procedure. You can be reimbursed under Medicare and Medicaid for performing ultrasounds, but reimbursement is lower.

How many of your patients might need the service? Patients with diabetes, vascular disease, heart conditions and others can benefit from ultrasound. If you think you'll use the equipment (and be reimbursed) at least 10 times per month, it's probably worth your investment. Of course, you'll also need to ensure that you'll be performing ultrasounds frequently enough to maintain your skills.

How will your staffing be affected? A trained medical assistant can extend physician time by performing the procedure, leaving only the reading of the ultrasound to the physician. Keep in mind that if someone else reads the ultrasound, you won't be reimbursed for the professional component of the procedure (usually about 35 percent to 40 percent of collections). There are courses available that can train you to read and perform ultrasounds.

How much will the equipment cost? Over the last 10 years, ultrasound prices have dropped dramatically, and quality, used, color-enhanced machines are now available for between $15,000 and $50,000. Don't be afraid to finance the ultrasound over time, if necessary.


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Copyright © 2000 by the American Academy of Family Physicians.
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