Understanding explanation of benefits (EOB)

Medicare

Medicare requires the ordering provider to supply diagnostic codes of why lab work is being performed. Medicare generally does not pay for “routine lab work” and the patient will be responsible for payment in these scenarios. To request a Medical Necessity booklet please call (800) 633-4227 or (877) 486-2048.

If the diagnostic codes provided do not justify medical necessity or if a certain test has frequency limitations, we may ask for the patient to sign an Advanced Beneficiary Notice that states we are uncertain if Medicare will pay for this and the patient may be responsible for payment. A valid ABN list the test(s), gives a reason why the test(s) may be denied, and has the patients’ signature that if the test is denied, the patient will be fully responsible for payment.

If Medicare denies a test as not medically necessary or routine, PLA will verify that an ABN was signed and bill the patient. If an ABN was not signed, and client collected the specimen(s) in their office, PLA will have no recourse except to bill the requesting physician for the test(s) ordered, since failure to do so could invoke the anti-kickback statutes that pertain to physician/laboratory relationships.

If an ICD10 code or diagnosis is not written on the requisition or submitted with an electronic order, PLA will contact the client by fax to obtain an ICD10 code. If the ICD10 code given does not justify medical necessity, PLA will attempt twice to notify the client.

We urge the patient to call their physician if there is any question on the diagnostic code that is being submitted. Your physician will need to contact PLA if a change in diagnosis codes is needed.

Self Pays

Patients are encouraged to pay at the time services are rendered or must supply address and phone number to be billed. We offer a 50% discount to all self pay patients.  If  payment is rendered at the time of service or within 30 days, we will apply an additional 10% discount.

Insurance Filing

Pathology Laboratory Associates will file Primary and Secondary with any insurance so long as all required billing information is provided by the patient and/or client. Depending on plan and whether PLA is in-network, patients may be responsible for the entire bill, co-pay or deductibles. It is the patient’s responsibility to verify if PLA is in-network lab.

Required information for Insurance billing:

• Front and Back copy of Insurance Card
• Patient Name
• Patient Address
• Patient SSN
• Patient DOB

Pathology Laboratory Associates offers three convenient billing options to meet the needs of our clients.

• Charges can be billed to the individual client account
• PLA can file with their patient’s insurance
• PLA can bill the patient directly

Client Bills

Client bills are sent as a monthly statement itemizing dates of testing, patient names, tests requested and associated charges.

Insurance

Pathology Laboratory Associates will file Primary and Secondary with any insurance (except those listed as Non-Contracted) if all the billing information is received. Depending on plan and whether PLA is in-network, patient’s may be responsible for entire bill, co-pay or deductibles
Required information for Insurance billing:

• Front and Back copy of Insurance Card
• Patient Name
• Patient Address
• Patient SSN
• Patient DOB
• Patient Billing Information

Understanding Your EOB

An Explanation of Benefits (EOB) is the documentation your insurance company sends to explain how your claim was processed. The insurance payment is sent to Pathology Laboratory Associates and a copy of the EOB is sent to you, in order for you to determine how much you may owe. Please remember that the Explanation of Benefits (EOB) that you receive from your insurance company is not a bill. If Pathology Laboratory Associates determines that your insurance processed your claim incorrectly, we will appeal that claim to your insurance company. Do not pay anything until you receive a billing statement from Pathology Laboratory Associates.

Charge Amount

This is the amount charged by Pathology Laboratory Associates for each test performed.

Allowed Amount

This is the amount your insurance company allows for each test before deductibles and coinsurance. Each insurance company determines their allowable rates for each participating provider.

Deductible

This is the amount that must be paid by the patient before insurance will begin reimbursing for covered services. Deductibles generally must be met each year. They are generally accumulated for all medical services combined.

Coinsurance

This is the portion of allowed charges that is the responsibility of the patient. Most insurance companies apply a percentage due as coinsurance after deductibles.

Amount Paid

This is the amount paid by the insurance company after all adjustments, coinsurance and deductibles have been taken out.

Contract Adjustment or Excess of UCR

This is the portion of the charge that is greater than the amount allowed by the insurance company. If Pathology Laboratory Associates is contracted with the insurance company, this amount is not the patient’s responsibility. If there is no contract between our lab and the insurance company, this amount is owed by the patient. “UCR” stands for usual, customary and reasonable. Each insurance company sets its own UCR. This does not mean that this test has been overcharged.

Non-Covered

This is a charge that is excluded from your contract and is non-payable by your insurance company. Some reasons could be that the procedure is considered investigational by your particular insurance company, a non-covered diagnosis was provided by the physician office or the test has been performed too frequently for the diagnosis given. In some cases a test may not be covered by your particular plan.   You may be responsible for these charges and this amount will show in the patient responsibility column. The patient responsibility column is the amount you may owe Pathology Laboratory Associates. This amount includes coinsurance, deductible and non-covered service amounts.