113 E. 4th Street, Michigan City, IN 46360 | Phone: 219-873-3130

FAQ

Habla Espanol?

  • No. Le pedimos respetuosamente a nuestros pacientes que hablen Espanol que tengan un interprete cuando hablen a nuestra oficinas si no pueden hablan Ingles.
  • No. We respectfully ask our Spanish speaking patients to have an interpreter available when calling our business office if communicating in English may be a barrier.

Why does my statement say that my insurance provider cannot identify me?

  • The information we need to bill is collected by the admissions department where your specimen was obtained. If the hospital, surgery center, doctor’s office or independent laboratory miskeyed information, we will receive erroneous data.
  • When a patient calls, mails or faxes new insurance information to us, we promptly update the billing record. However, we do not have a mechanism to share that information with the admissions department where your specimen was obtained. Nor does the admissions department have a mechanism to pass new information along to us. Therefore, it is important to contact all service providers when updated information is needed to bill correctly.

What is an automated test?

  • Many tests in the clinical laboratory are performed on sophisticated instruments allowing the operator (medical technologist or technician) to analyze large numbers of samples or perform a wide range of tests on a single sample using automated technology. Medical technologists and technicians work under the direction of a pathologist when operating the instruments in the clinical laboratory.

What services do pathologists render on automated tests?

  • Pathologists are responsible for every test performed in the laboratory. They steer the choice of which instruments, reagents, or test kits will be used. They govern the quality, normal ranges, and critical values. They determine reflex testing protocols and interact with technologists and technicians as needed for troubleshooting or validation. They assure all government regulations concerning laboratory operations are adhered to at all times which assures the convenience and availability of a large test menu. They are available to discuss results as needed with the ordering physician to determine the best treatment or further testing.

Why do pathologists bill with a 26 modifier?

  • As the health care payment system has evolved over the past 40 years, many hospitals and physicians have found it preferable to maintain autonomy rather than enter into an employer/employee type relationship. As such, each bills for their own services separately.
  • Unlike other physician specialties, the CPT (procedure) codes designating pathology services are not unique for the technical and professional components. Therefore, the hospital bills for the technical portion using a TC modifier while the pathologist bills for the professional portion using a 26 modifier.
  • This style of billing is predominant in pathology groups across the nation. It is upheld by both the American Medical Association (AMA) and the College of American Pathologists (CAP).

What is a medically necessary service?

  • Insurance companies and other third-party payers match the CPT (procedure) code on a claim to the ICD-9 (diagnosis) code to determine whether the service will be paid. The CPT describes what service was performed. The ICD-9 code describes the reason the doctor performed the service. If the reason for testing does not align with the test performed often the service is denied as medically unnecessary.
  • Beneficiaries and policyholders should consult their coverage documents to determine if a claim has been paid correctly. Many plans exclude screening services, experimental procedures, or have other stipulations that effect how a claim is paid.
  • If your claim has been denied as medically unnecessary, we suggest you contact your ordering physician. Because space is limited on the forms used to order laboratory tests, physicians must limit the amount of information given. Often, however, there are documented conditions, signs, symptoms, etc., that would allow the physician to submit a different diagnosis code than supplied on the original order. In that circumstance, the ordering physician can provide the documentation to the billing office and the claim will be re-filed.

What is UCR?

  • UCR is an acronym used by many payers for usual, customary, and reasonable. Insurance companies typically pay the lowest of the three.
  • Usual refers to the fee a physician routinely charges for a service.
  • Customary refers to the fee that most physicians within a particular geographic area charges for a service.
  • Reasonable refers to the fee amount deemed fair and equitable for a given service by a court deciding a dispute.
  • Patients are only affected by UCR if the charge exceeds the amount the insurance company has decided it will pay and the payer and provider are not under contract with each other.

Can I obtain medical records from your office?

  • Pathologists are not typically custodians of medical records. Test results are a special section in the patient chart which is held by your physician. To obtain a copy of lab results or other documents of your medical record, please inquire with the physician ordering your test(s).
  • Federal regulations also restrict the ability of laboratories to provide test results directly to patients, and instead direct the laboratories to provide the results to the ordering practitioner.

What does it mean if my insurance company says services were out-of-network?

  • Out-of-network refers to the lack of contracted status between the insurance company and the service provider. Typically, claims to an out-of-network provider are paid at a lower rate. There also may be a separate deductible amount that must be met before the insurance company makes payment to a claim. Both result in more patient responsibility for payment.
  • For optimal coverage, it is important for patients to know the contract status of their service providers. We encourage you to inquire with your insurance company prior to having testing done. Be aware however, that most insurance companies offer a “facility exception” when adjudicating pathology claims which means when the facility at which your test(s) or surgery was performed is contracted with your insurance company, your pathology services may be paid at an in-network rate even if the pathologist or pathology group is not contracted.