Billing

Rhode Island has become the latest state to take steps in an effort to address the ongoing challenge of surprise bills for medical services.

As the Providence Journal reports, state lawmakers are sponsoring legislation that would provide for a dispute resolution process for emergency services and surprise bills for medical services performed by nonparticipating (i.e., out-of-network) healthcare providers, regardless of whether the services are provided within or outside of the state.

The bill — H-5012 — is modeled after similar medical billing laws passed in Connecticut, New York and Florida. California is another state that has recently seen its lawmakers take action in this area, although some physicians have pushed back against it.

The Rhode Island bill's cosponsors include House Judiciary Chairman Cale P. Keable (D-Burrillville), Rep. Carol Hagan McEntee (South Kingstown), and Rep. Lauren H. Carson (D-Newport).

Craven, quoted in the Providence Journal report, stated, "My hope is that this legislation can ease the financial burden on Rhode Islanders when medical emergencies and surprises take place without sacrificing needed and potentially life-saving care."

What is Surprise Medical Billing?

A surprise medical bill — or balance billing — happens when a patient receives a bill from a doctor, hospital or other healthcare provider who is not part of the patient's health plan's network. Often, consumers do not know they are receiving care from out-of-network providers.

For example, a patient goes to an in-network hospital for emergency care and is treated by an out-of-network doctor. The doctor and the hospital each bill $1,000 for their services, and the health plan pays them each $400. The in-network hospital can only bill the patient for copays, deductibles, and coinsurance amounts. The doctor, however, may bill for the $600 that the health plan did not pay, as well as any copays, deductibles, and coinsurance.

As Brookings reports, "Over a dozen states have enacted important protections and federal and state officials have proposed additional remedies, but these efforts are incomplete, and they pursue a variety of different strategies."

The Centers for Medicare & Medicaid Services (CMS) will increase reimbursement for toxicology drug confirmation codes in 2017.

Background

For 2016, CMS implemented four new HCPCS G codes for definitive drug testing:

  • G0480
  • G0481
  • G0482
  • G0483

CMS priced these codes using a crosswalking formula. The first two tests performed were paid at the full price of the crosswalk CPT code 82542 and the remaining tests within that code were paid at 25% of the crosswalk price.

CPT Code

Crosswalk Formula

G0480

2*82542 + 5*.25*82542

G0481

2*82542 + 12*.25*82542

G0482

2*82542 + 19*.25*82542

G0483

2*82542 + 27*.25*82542

Changes for 2017

CMS is modifying the current formula to establish the price for these codes to allow four tests to be priced at the full crosswalk price:

CPT Code

Crosswalk Formula

G0480

4*82542 + 3*.25*82542

G0481

4*82542 + 10*.25*82542

G0482

4*82542 + 17*.25*82542

G0483

4*82542 + 25*.25*82542

CMS also modified the descriptors for the definitive  drug testing codes. They now read as follows (underlined text indicate additions):

G0480 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control f or matrix ef f ects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control f or instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed

G0481 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control f or matrix ef f ects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control f or instrument variations and mass spectral drif t); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed

G0482 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control f or matrix ef f ects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control f or instrument variations and mass spectral drif t); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed

G0483 — Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to GC/MS (any type, single or tandem) and LC/MS (any type, single or tandem and excluding immunoassays (e.g., IA, EIA, ELISA, EMIT, FPIA) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control f or matrix ef f ects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control f or instrument variations and mass spectral drif t); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed

Providers of a clinical lab billing service should note these and the other changes that were the result of the recent Annual Laboratory Public Meeting.

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