Billing & Crediting Policies

Fee Schedule & Billing

Our fee schedule is published separately on an annual cycle and is available through the office. A contract billing summary and detailed invoice, issued the first week of every month, covers those test procedures requested during the previous calendar month. All payments are due 45 days from the date of the related invoice and are independent of any reimbursement received by the client from patients or third-party payers. Questions regarding clarification on any invoice should be directed to the office staff.

Medicare Coverage for Lab Testing

• Consistent with federal regulations, charges for tests you have referred on Medicare or Medicaid patients will be billed directly to the carrier by SSM Health St. Mary's Hospital - Madison. Appropriate Medicare/Medicaid numbers and ICD-9 codes must be included at the time the test is ordered.
• Each individual component of any panel must be medically necessary to qualify for reimbursement. Medicare will not pay for non FDA-approved tests or for screening tests.
• If there is a reason to believe that Medicare will not pay for a test, the patient should be informed of that fact. The patient should then sign an Advance Beneficiary Notice (ABN), to indicate that he or she is responsible for the test if Medicare denies payment.
• If no ABN was received with the specimen before processing or there was inadequate documentation and payment was denied by the fiscal intermediary, lab services will bill the client for the services that were provided.
• The client accepts financial responsibility for any test ordered where insufficient diagnosis information has been given and/or are considered not medically necessary according to Medicare or Medicaid.
• In the event a client discovers that the patient is actually a Medicare patient after a test was submitted and completed, the client will be allowed a 45-day grace period after the receipt of the invoice to provide appropriate Medicare information for lab services to bill Medicare appropriately. The client account will be credited for the initial charge. The client will be responsible to pay lab services for any test for which information received exceeds the 45-day grace period.
• If these lab orders are being done in conjunction with an inpatient hospital stay at the same time of order or planned within the next 72 hours, billing must be included in the DRG billing done at the hospital where the patient is/or will be.

Medicaid Billing

If the patient's primary insurance coverage for laboratory services is Medicaid, lab services will invoice Medicaid directly. The client is not responsible for payment of covered services under Medicaid when it is the primary insurance.