SB1630sam003 98TH GENERAL ASSEMBLY

Sen. William R. Haine

Filed: 4/12/2013

09800SB1630sam003 LRB098 08625 MGM 44294 a

AMENDMENT TO SENATE BILL 1630

AMENDMENT NO. ______. Amend Senate Bill 1630, AS AMENDED, by replacing everything after the enacting clause with the following:

"Section 5. The Illinois Clinical Laboratory and Blood Bank Act is amended by adding Section 7-105 as follows:

(210 ILCS 25/7-105 new)

Sec. 7-105. Direct billing of anatomic pathology services.

(a) A clinical laboratory that provides anatomic pathology services for patients in this State shall present or cause to be presented a claim, bill, or demand for payment for these services only to:

(1) the patient directly;

(2) the responsible insurer or other third-party payor;

(3) the hospital, public health clinic, or nonprofit health clinic ordering such services;

(4) the referring laboratory, excluding a laboratory of a physician's office or group practice that does not perform the professional component of the anatomic pathology service for which the claim, bill, or demand is presented;

(5) governmental agencies, specified public or private agents of government agencies, or organizations, working on behalf of the recipient of the services.

(b) Clinical laboratories shall not, directly or indirectly, charge, bill, or otherwise solicit payment for anatomic pathology services unless the services were rendered by the clinical laboratory or by the laboratory's employee or agent in accordance with Section 353 of the Public Health Service Act (42 U.S.C. 263a).

(c) No patient, insurer, third-party payor, hospital, public health clinic, or nonprofit health clinic shall be required to reimburse any clinical laboratory for charges or claims submitted in violation of this Section.

(d) Nothing in this Section shall be construed to mandate the assignment of benefits for anatomic pathology services as defined in this Section.

(e) For purposes of this Section, the term "anatomic pathology services" means:

(1) histopathology or surgical pathology, meaning the gross and microscopic examination performed by a physician or under the supervision of a physician, including histologic processing;

(2) cytopathology, meaning the microscopic examination of cells from the following: (i) fluids, (ii) aspirates, (iii) washings, (iv) brushings, or (v) smears, including the Pap test examination performed by a physician or under the supervision of a physician;

(3) hematology, meaning the microscopic evaluation of bone marrow aspirates and biopsies performed by a physician, or under the supervision of a physician, and peripheral blood smears when the attending or treating physician or technologist requests that a blood smear be reviewed by a pathologist;

(4) sub-cellular pathology or molecular pathology, meaning the assessment of a patient specimen for the detection, localization, measurement, or analysis of one or more protein or nucleic acid targets; and

(5) blood-banking services performed by pathologists.

(f) The provisions of this Section do not prohibit billing of a referring laboratory for anatomic pathology services in instances where a sample or samples must be sent to another laboratory for consultation or histologic processing. For purposes of this subsection (f), the term "referring laboratory" does not include a laboratory of a physician's office or group practice that does not perform the professional component of the anatomic pathology service involved.

(g) The Department may revoke, suspend, or deny renewal of the license of any clinical laboratory who violates the provisions of this Section.

(h) A person who receives a bill for an anatomic pathology service made in knowing and willful violation of this Section may maintain an action to recover the actual amount paid for the bill.

(i) This Section does not prohibit a referring physician who takes a patient specimen from charging a patient or a payor an acquisition or processing charge when:

(1) the charge is limited to actual costs incurred for specimen collection and transportation; and

(2) the charge is separately coded or denoted as a service distinct from the performance of the anatomic pathology service, in conformance with the coding policies of the American Medical Association.

(j) Nothing in this Section shall be construed to prohibit a referring physician from sending a patient's specimen to any laboratory providing anatomic pathology services.

(k) This Section does not apply to facilities licensed under the Hospital Licensing Act or the University of Illinois Hospital Act or clinical laboratories owned, operated by, or operated within facilities licensed under the Hospital Licensing Act or the University of Illinois Hospital Act, when billing:

(1) for inpatient services or outpatient services from those facilities; or

(2) any other facility licensed under the Hospital Licensing Act or University of Illinois Hospital Act.

(l) A physician who orders and who does not perform a component of anatomic pathology services shall notify in writing a clinical laboratory or physician who performs or supervises those services for a patient that the laboratory performing the services is not participating in the patient's insurance or third-party payor network.

(m) When a physician or laboratory receives written notification as provided under subsection (l), notwithstanding the prohibitions of this Section, the laboratory or physician providing the anatomic pathology service shall bill the physician that refers the patient specimen.

(n) A physician that receives a bill for services in accordance with subsection (m) may bill an insurer or other third-party payor, provided that:

(1) the physician discloses in a bill for the services presented to insurer or other third-party payor:

(A) the name and address of the physician or laboratory that provided the anatomic pathology service; and

(B) the actual amount paid or to be paid for each anatomic pathology service provided to the patient by the physician or laboratory that performed the service;

(2) the bill for anatomic pathology services is not directly or indirectly increased from the amount required to be disclosed under subparagraph (B) of paragraph (1) of this subsection (n) in any bill presented to the third-party payor; and

(3) the billing by a referring physician as provided under subsection (m) is not contrary to the terms, contract, or policies upon which the insurer or other third-party payor provides payment to the billing physician.

Section 10. The Medical Practice Act of 1987 is amended by adding Section 70 as follows:

(225 ILCS 60/70 new)

Sec. 70. Direct billing of anatomic pathology services.

(a) A physician that provides anatomic pathology services for patients in this State shall present or cause to be presented a claim, bill, or demand for payment for these services only to:

(1) the patient directly;

(2) the responsible insurer or other third-party payor;

(3) the hospital, public health clinic, or nonprofit health clinic ordering such services;

(4) the referring laboratory, excluding a laboratory of a physician's office or group practice that does not perform the professional component of the anatomic pathology service for which the claim, bill, or demand is presented;

(5) governmental agencies, specified public or private agents of government agencies, or organizations, working on behalf of the recipient of the services.

(b) Except for a physician at a referring laboratory that has been billed pursuant to subsection (f), physicians shall not, directly or indirectly, charge, bill, or otherwise solicit payment for anatomic pathology services unless the services were rendered personally by the physician or under the physician's direct supervision in accordance with Section 353 of the Public Health Service Act (42 U.S.C. 263a).

(c) No patient, insurer, third-party payor, hospital, public health clinic, or nonprofit health clinic shall be required to reimburse any physician for charges or claims submitted in violation of this Section.

(d) Nothing in this Section shall be construed to mandate the assignment of benefits for anatomic pathology services as defined in this Section.

(e) For purposes of this Section, the term "anatomic pathology services" means:

(1) histopathology or surgical pathology, meaning the gross and microscopic examination performed by a physician or under the supervision of a physician, including histologic processing;

(2) cytopathology, meaning the microscopic examination of cells from the following: (i) fluids, (ii) aspirates, (iii) washings, (iv) brushings, or (v) smears, including the Pap test examination performed by a physician or under the supervision of a physician;

(3) hematology, meaning the microscopic evaluation of bone marrow aspirates and biopsies performed by a physician, or under the supervision of a physician, and peripheral blood smears when the attending or treating physician or technologist requests that a blood smear be reviewed by a pathologist;

(4) sub-cellular pathology or molecular pathology, meaning the assessment of a patient specimen for the detection, localization, measurement, or analysis of one or more protein or nucleic acid targets; and

(5) blood-banking services performed by pathologists.

(f) The provisions of this Section do not prohibit billing of a referring laboratory for anatomic pathology services in instances where a sample or samples must be sent to another physician or laboratory for consultation or histologic processing. For purposes of this subsection (f), the term "referring laboratory" does not include a laboratory of a physician's office or group practice that does not perform the professional component of the anatomic pathology service involved.

(g) The Department may revoke, suspend, or deny renewal of the license of any physician who violates the provisions of this Section.

(h) A person who receives a bill for an anatomic pathology service made in knowing and willful violation of this Section may maintain an action to recover the actual amount paid for the bill.

(i) This Section does not prohibit a referring physician who takes a patient specimen from charging a patient or a payor an acquisition or processing charge when:

(1) the charge is limited to actual costs incurred for specimen collection and transportation; and

(2) the charge is separately coded or denoted as a service distinct from the performance of the anatomic pathology service, in conformance with the coding policies of the American Medical Association.

(j) Nothing in this Section shall be construed to prohibit a referring physician from sending a patient's specimen to any laboratory providing anatomic pathology services.

(k) A physician who orders and who does not perform a component of anatomic pathology services shall notify in writing a clinical laboratory or physician who performs or supervises those services for a patient that the laboratory performing the services is not participating in the patient's insurance or third-party payor network.

(l) When a physician or laboratory receives written notification as provided under subsection (k), notwithstanding the prohibitions of this Section, the laboratory or physician providing the anatomic pathology service shall bill the physician that refers the patient specimen.

(m) A physician that receives a bill for services in accordance with subsection (l) may bill an insurer or other third-party payor, provided that:

(1) the physician discloses in a bill for the services presented to insurer, or other third-party payor:

(A) the name and address of the physician or laboratory that provided the anatomic pathology service; and

(B) the actual amount paid or to be paid for each anatomic pathology service provided to the patient by the physician or laboratory that performed the service;

(2) the bill for anatomic pathology services is not directly or indirectly increased from the amount required to be disclosed under subparagraph (B) of paragraph (1) of this subsection (m) in any bill presented to the third-party payor; and

(3) the billing by a referring physician as provided under subsection (l) is not contrary to the terms, contract, or policies upon which the insurer or other third-party payor provides payment to the billing physician.

Section 99. Effective date. This Act takes effect December 31, 2013.".