Collaborate on Lab Bill Format for Government with Ease Using airSlate SignNow

Lab bill format for Government

thanks for joining us at lighthouse lab services for today's webinar how labs can comply with new surprise billing rules particularly overseen by the no surprises act the new federal surprise billing regulation that went into effect on january 1st i'm going to quickly introduce our speakers today my name is alex mitchell i'm a communications manager with the lighthouse marketing team our guest speaker today is daniel tangor a partner with robinson and cole a national law firm with a focus on health care law ms tangore represents and advises on a broad range of health care providers including clinical laboratories long-term care facilities behavioral health providers substance abuse providers physician group practices and licensed health care providers she is a member of the health law group which consists of a team of experienced health care lawyers trained to advise clients on meeting business objectives within the confines of a complicated legal and regulatory environment ms tangore's specialties include advising clients on operational and compliance issues federal and state fraud and abuse laws including stark law anti-kickback statue and ekra hipaa and other regulatory matters and we want to really say thank you for her time today we greatly appreciate it danielle will be joined by ann lambrechts from our team with the vachette rcm division of lighthouse and serves as lighthouse's vice president of rcm consulting heading up the division's day-to-day operations with more than 20 years in the medical insurance and billing industry her experience provides for an insightful analysis of revenue cycle and payer trends impacting reimbursement and ms lambrix also holds an msj in health and hospital law so thank you to anne for her time today as well and now for those of you who may be joining us for the first time today i'll just do a little bit about lighthouse with almost 20 years of experience lighthouse lab services has become the nation's leading and most trusted and full-service medical laboratory consultated recruiting firm whether you're looking to start a lab or looking to grow your current business we offer labs a way to accelerate their success and again if you're interested in learning more please reach out to us after the conclusion of this webinar and with that i'll turn it over to danielle thanks so much alex good afternoon everyone it's a pleasure to be here talking to you about this with ann as well um just a quick disclaimer i'm not this isn't attorney client advice um it's giving general information i'm not creating a specific attorney-client relationship um and as you are probably aware uh this the no surprises act is still in development with regulations being promulgated by the government as we speak um and litigation as well so all of this is subject to change but we will address that as we go along so just as a little bit of a background this uh the federal law was passed in december of 2020 regulations began being promulgated mid-year last year it became effective as of january 1st 2022 so this is the first year that we're in it the intent of the law and i think it's important to keep this in mind is to protect consumers from surprise medical bills uh that can arise there was a lot of publicity um particularly with air ambulance but also high laboratory bills from out of network laboratories surprising patients and that's what really spurred this law i so you have to remember that patients um may not be aware that they're going to an out of network facility particularly for the ancillary services such as laboratory work um and that they receive bills that may be unexpected and this federal regime is to address all of those issues uh and we're they're currently in the press cms is currently in the process of implementing various roles uh as as we go along uh there's also state surprise billing laws that you should be aware of um this chart take taken from the commonwealth fund i think particularly highlights it well there are balance spelling protections surprise billing laws in several states um you know with the dark green being the most comprehensive and then there are you know other ones that are less comprehensive and then some states are still working on passing or considering their own version of surprise mailing laws at the state level and we will discuss as we go forward in the presentation the interplay between the federal and the state laws so one of the biggest questions in figuring out the no surprises act is exactly when does it apply and it applies in emergency services some post-emergency stabilization services but most importantly what we're going to focus on for the majority of today are non-emergency services provided at certain in-network facilities so you have to we'll get to this but it's important to know what a network facility is defined as under the law it's defined as a hospital a hospital outpatient department a critical access hospital or an ambulatory surgical center the regs aren't vital so it is possible that there will be an additional list or additional facilities that are added in the commentary one of the um debates uh was whether urgent care centers should be included in this list we'll we'll have to wait and see whether they're ultimately included uh and then it also is important to understand whether you're a participating or non-participating provider and those that you are working with are whether they are participating or not participating so for a lab what you need to identify is whether first and foremost the test is a covered service if it's a covered service that means that it is covered and billable to a commercial payer so the nose prices act applies to items and services um provided to individuals enrolled in private and commercial healthcare plans including employment-based group health plans individual group health coverage federal employee health benefit health plans those plans that are sponsored by state and local government employers and some other ancillary ones but what it doesn't apply to is any beneficiary enrollees in medicare medicaid or veteran veteran affairs or tricare so if it is a covered service uh that's your first question and then you have to understand whether the specimen collected was part of a visit and a visit is defined as one that is part of a participating health facility and includes ancillary services such as laboratory work whether or not you the lab are furnishing such items or services at the physical location of the facility so you have to determine whether the specimen was collected in an emergency at a hospital at a hospital outpatient department at a critical access hospital at an ambulatory surgical center or if you're a hospital outreach lab you have to understand that the no surprises act does apply and then you need to figure out if you are an independent laboratory whether the visit um at the hospital for example is that is in network we'll take these in part so the first issue is whether it's a covered service so is the test um covered under the in-network benefits in terms of the individual's health plan if you have a more esoteric test or something that is not generally covered by insurance then this is not going to apply if it is covered though by the individual's insurance then the support no surprises act rules of balance billing apply so then the important part is whether it's whether your specimen comes from one of those four the hospital the hospital outpatient department or if you are a hospital or hospital outreach laboratory then you have to consider all of the requirements of the no surprises act if you're an independent lab and you are doing reference work for example for a hospital then the no surprises act applies and so it would be falling into this category of non-emergency services that are part of a visit as an out-of-network laboratory you cannot balance bill for non-emergency lab tests that are part of a visit at an in-network hospital for example interestingly um as part of the rules the cms and the government decided that ancillary service providers such as laboratories are not able to use um the notice and consent exemption for balance billing so what this means is that you cannot give notice to the patient prior to the test being run and get consent to bill them for the out of network charge so simply if you're an out of network lab providing services at a hospital hospital outreach determinant department or ambulatory surgical center you cannot balance bill a patient or seek consent to bill for out-of-network costs you are limited solely to the in-network cost-sharing amount and the in-network payment rate so what is that rate that rate will depend on certain circumstances including any state laws that establish reimbursement amounts so think of those states we saw a couple slides ago and their surprise billing or whether there is an all-payer rate setting model and then if neither of those scenarios apply the out-of-network rate is either the rate agreed to by both the plan and the laboratory or if you cannot agree to such rate you would have to go through the independent dispute resolution process which we'll talk about briefly the other require requirement is that a provider so whether you're a health care provider or if you're at a healthcare facility such you know again the hospital the hospital outpatient department ambulatory surgical center emergency department or if you're providing services and contracting um with those in healthcare facilities then you have to post publicly and work collaboratively to distribute a one-page notice on the no surprises act protections and balance billing laws both federal and state um i think we covered this but i just wanted to give you an example of what we've talked about for example if an individual with an employer-sponsored health plan is referred to a local in-network hospital outpatient department for a biopsy and the pathologist performing the review is out of network even though the hospital is in network then the nose prices act applies the pathologist cannot build a patient um more than the in-network cost-sharing amount and that rate will be set as we just discussed about nor can the pathologist obtain consent to waive the balance billing protections and then going back to the public notice if you are providing services as part of a visit at an inpatient patient facility such as a hospital or if you are a hospital outreach laboratory um or a lab at an inventory surgical center then you have to publicly post on your website and provide notice to patients regard regarding all of this the state balance billing and there are model consents and notices posted on cms's website that you should take a look at in addition you have to have contact information for state and or federal agencies that an individual can contact to report where a patient can report a provider or health care facility for violation of the balance billing protections and to go through the independent dispute resolution process if it's in if the patient is able to use that as well you as a provider are not required to make the disclosures if you don't furnish items and if you're an independent lab and you don't work with a hospital or receive samples from a hospital outreach laboratory or ambulatory surgical center so just briefly in the event that you have to avail yourself of the independent dispute resolution process the process requires that after 30 days of negotiation between you and the insurance company determine whether you can agree to a rate then you can initiate an independent dispute resolution process where the parties will select a certified entity and if you cannot agree to a neutral one one will be appointed uh you'll both sides will submit payment offers and supporting documentation as to the appropriate rate and ultimately the dispute resolution entity will deliver binding ruling on what the rate should be the idr process has solicited and put forth a certification process for dispute arbiters to be qualified to do this process and we're gonna skip for now the good faith estimates but um there are provisions in the law about good faith estimates depending um if you're a hospital a hospital outreach laboratory that you should work with your facility to to deal with um so for the the timeline once you start start the idr process um there are a variety of deadlines that you have to be aware of we're not going to go through all of these but ultimately there is a process that you have to go through there are also factors that the arbitrator will look to and right now there's a conflict or perceived conflict between the how the this independent dispute resolution process will take place um both the aha and ama filed a lawsuit over this process on december 9th in d.c they have argued that the regulations exceed the department's statutory authority because the department created a in their event opinion a different focus for the factors that are weighed under the idr process it's their position that this process put forth in the interim final rule issues the rule to be one-sided in favor of the insurers the insurers have failed in mikis briefs supporting how the department uh interpreted the the law and the parties are currently in the um still in process of having that lawsuit debated decided we'll have to wait for that for a while as that winds its way through the court and we'll have to see if that changes the overall process for the independent dispute resolution process well thank you very much thank you very much for that uh portion danielle before we turn it over to ann here with some comments from danielle for next steps and looking ahead i just wanted to offer to everyone if you'd like to follow up with uh danielle from today's presentation you may do so by clicking that button and filling out that form uh if you don't want to fill out the form right now we'll also have her email address available at the end so please if you have questions follow up with her at her team they'll definitely be able to get you squared away ann thanks alex thanks danielle um i know uh this for me has been a very interesting and almost complicated process the the no surprises act has been around and as danielle pointed out we we've seen this surprise bill laws being passed throughout the country various states so we're all pretty familiar with surprise bill and and what that means but again the complexity of the law and understanding how this impacts you and your business i'm sorry can you not hear me no you're fine ann i'm sorry i think the microphone just got unmuted okay perfect thanks alex um sorry about that um so again i just uh wanted to point out some things that we're recommending as far as next steps and looking ahead as as labs and pathology groups and and again people that we're working with are are trying to navigate the no surprises act my guidance has been if you're a hospital-based pathology group or a laboratory you may have already been reached out to by your facility by administration or or for the insurance department they may be coming to you looking for a list of payers that you're participating with so um you're going to want to review those contracts and understand who you're participating with i mean you should have a pretty good gauge on who you're in network with and out of network with but it's a good exercise to look at that and again explore if you're out of network what your processes are so making sure that contracts if you have a third-party biller if you're using a billing software that the contracts are loaded appropriate in the system that your system is taking those uh in-network allowances as paid in full or if there's a patient out of pocket due to their in-network plan that's billing appropriately but you're not balance billing these patients if you're out of network so it's again ensuring that your contracts are loaded as well as your billing um vendor um is current with the with your patient billing policy and that they're able to identify um again the the difference between a balance bill between your bill charge and an allowed amount versus a patient out of pocket expense a deductible copay coinsurance etc and that they're not balance billing we really want to make sure you're not balance billing with this new law in place and finally i think it's really important to tie that all together to make sure that you have some sort of billing compliance plan in place again if you're hospital based many of my groups you know utilize the hospitals compliance plan but what we're doing is is carving that out particularly when it comes to patient billing and making sure that the group and or the laboratory is in line with patient billing laws and that they have those policies outlined it's very clear and specific um what uh you know what the biller should be doing in regards to patient balances and so having those in place and and walking through that again ensures that you're compliant and that your everybody is in line with what should be happening um so we highly recommend to do that reviewing your billing compliance plan danielle is there anything else that you would recommend yes thanks ann i think those are all amazing points um part of both the review of your billing compliance plan and as to your first point about uploading your contracts you also need to review the state laws so for the states that you are soliciting or receiving samples from most of the state surprise act laws are based on where the patient lives but some may be based somewhere else you need to do a full review of those state laws where you are either in or receiving samples from make sure that those rules are also uploaded into the system and incorporated into your billing compliance plan some of the state laws do have requirements that extend past hospitals and urgent care centers or you know emergency settings and apply to even primary care settings and things or physician offices and that is completely dependent upon the state uh it so it kind of creates a very complex um maze of laws for laboratories to understand um and that's why this reviewing your billing compliance plan and making sure that all your um parameters are set in within your billing system is incredibly important well thank you for that and and danielle that was extremely informative and i see we have a few uh questions that we're going to try to tackle here right ahead of that i want to also give the offer for anyone to follow up with our rcm team if you're interested in learning more about lighthouse and bushette's rcm services feel free to fill out that form or follow up at the email address listed below uh turning to the questions here we'll start with one from jay flanagan do the non-surprise laws in states noted in the table shown earlier in the presentation apply to clinics and physician facilities beyond hospitals etc and i would think that would probably uh depend on the state you're in am i correct with that alex you are correct it will um depend upon the state or the state that the patient is in so you'll have to review each state law to see whether it applies or not but it's quite possible as i i just mentioned that it may apply um to other settings both clinics physician facilities primary care practices and the like thank you danielle and i saw someone also just asked a question and i think this is a particularly hot one do you know of any resource where these state laws are tidally bundled up to uh review or is this kind of uh playing a game a whack-a-mole and having to track them all down um there seems to be a few resources that have been published on the web i haven't reviewed all of them i think the commonwealth that i i took that um the map earlier has a good starting point um but i would say that you know you should consult your attorney or your in-house counsel your compliance officer to make sure that each law is reviewed independently you know because there are nuances that i don't think everything publicly posted goes into i'm in a second that i think it's very important to make sure that you have legal counsel an expert review of these laws to make sure that you're compliant um if you have uh you know uh just a regular shmo like me um reading it um you know i can have some good takeaways based on my expertise and knowledge of the industry um but when you get into some real detail of the of the um the policies and and guidance it's really it's good to have uh danielle on your side to to make sure that that you're really fine-tuning that letter of the law on on your practice thank you both ann and danielle moving on to a question from denise we are an independent lab and do not see patients we receive surgical specimens from hospitals slash clinics how would the non-surprise laws slash ballot balance billing apply directly to us i believe we might have touched on this a little bit earlier but is there anything additional we can say sure so i meant for that particular as an independent lab you would need to determine for the surgical specimens you're receiving if those hospitals are in network facilities if you are an out of network lab providing services to the hospital that the no surprises act absolutely applies to you so you would need to have an understanding um as to the specimens you're receiving whether you're in network um with those payers or not if you're not then you need to work with the hospital um regarding um you know determining those those samples are coming to you and you'll you'll have to comply with the no surprises act as we walked through including not balance billing those patients where you are out of network and the hospital is in that work thanks danielle uh jumping back to the state laws versus federal um i have a question from serena marshall here are the state laws based on practice location or the state the patient resides in it depends um most uh well i'm not gonna even say most um it can be both as to where the practice location or the patient lives and it is really one of those nuanced things where you have to read each state law to determine uh how that applies and i just stick with the theme here since we have more questions on state versus federal do the state laws generally supersede the federal laws no um this is one of those um also complex areas um state where the no surprises act is silent so take for example primary care physicians the state law will control um but that's not necessarily true where we're talking about hospitals um they're you know the gov federal government and the states are sometimes starting to publish how those laws intersect from each of their state um and so if you um or an independent laboratory out of network getting specimens from a hospital um the no surprises act um likely will control unless the state has even greater protections than what is set forth in the law um but if the law the state law for example allows balance billing in that circumstance that will not preempt the federal law okay and i believe we have question or time for one more question here so maybe we could expand a bit upon the good faith estimates with a question here since we didn't touch on those very much um jay asks are we correct to understand that labs must provide good faith estimates to anyone who requests one regardless of the facility type in regardless of the insurance coverage good faith estimates have to be provided and it depends whether we're talking about um uninsured self-pay or in the circumstances of the of the no surprises act applies so it's a little bit complicated and i think that one should probably go offline excellent okay i think uh we have a few questions still hanging out there but alex can we answer i i think i can answer ruth's uh question um and i think it was ruth but as far as billing for patients co-pays deductibles my understanding danielle and correct me i'm wrong if the insurance company processes at this point in 2021 if the insurance company processes um a balance to an out-of-network deductible we can balance we can bill that to the patient and i believe they're working on again for 2023 where the insurance company will need to provide the again out-of-pocket expense as if the patient went to an in-network facility but that's not firmed up yet so they're not going to start enforcing that until 2023 is that correct and i believe that's correct we're still in the process and that's one of the ones subject to potential change as we see the regulations come out this year you