Re: Billing Question

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Hi Joyce,

In a message dated 05/23/2000 4:49:55 PM Pacific Daylight Time, writes:

>  Is there a regulation regarding what should be billed for a reference test
>  not performed in your facility? 

This is covered in HCFA Pub 14-3, Medicare Carriers Manual, Part 3, Chapter 
III - Claims, Filing, Jurisdiction and Development Procedures.  Section 3045, 
Item 3045.6 'Physicians Billing for Purchased Diagnostic Tests (Other than 
Clinical Diagnostic Laboratory Tests).--'

>  Are we allowed to only bill the patient what we are billed by the 
>  laboratory? 

Yes!  This change occurred as a result of OBRA87 and took effect April 1, 
1988.  No mark up for purchased diagnostic tests.  From the above reference:

"If a physician's bill or a request for payment includes a charge for a 
diagnostic test (other than a clinical diagnostic laboratory test) which the 
physician did not personally perform or supervise, payment for the test may 
not exceed the lessor of:  1.  The actual acquisition cost (net any 
discounts); or
2.  The lower of the supplier's reasonable charge for the test."

This happened because physician's were getting testing done, paying for it 
then turning around and charging the patient or their insurance (read 
Medicare) an inflated amount for testing the physician did not personally 
perform or supervise.  

This would be the same as someone going to McDonalds and buying a Whopper for 
$4.00 when he could have purchased it for $2.00 at Burger King (Home of the 

>   If so - could you point me to the written regulation? 

The above reference is available at:

Let me know if you need more info.

Matt Bowers
Lab Manager
Visalia Path Med Grp
Visalia, CA  93291
o - (559)625-4605
f - (559)625-1315

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