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Sen. William R. Haine
Filed: 4/12/2013
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1 | | AMENDMENT TO SENATE BILL 1630
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2 | | AMENDMENT NO. ______. Amend Senate Bill 1630, AS AMENDED, |
3 | | by replacing everything after the enacting clause with the |
4 | | following:
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5 | | "Section 5. The Illinois Clinical Laboratory and Blood Bank |
6 | | Act is amended by adding Section 7-105 as follows: |
7 | | (210 ILCS 25/7-105 new) |
8 | | Sec. 7-105. Direct billing of anatomic pathology services. |
9 | | (a) A clinical laboratory
that provides anatomic pathology |
10 | | services for patients in this State shall present or
cause to |
11 | | be presented a claim, bill, or demand for payment for these |
12 | | services only to: |
13 | | (1) the patient directly; |
14 | | (2) the responsible insurer or other third-party |
15 | | payor; |
16 | | (3) the hospital, public health clinic, or nonprofit |
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1 | | health clinic ordering such
services; |
2 | | (4) the referring laboratory, excluding a laboratory |
3 | | of a physician's office or group
practice that does not |
4 | | perform the professional component of the anatomic
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5 | | pathology service for which the claim, bill, or demand is |
6 | | presented; |
7 | | (5) governmental agencies, specified public or private |
8 | | agents of government agencies, or
organizations, working |
9 | | on behalf of the recipient of the services. |
10 | | (b) Clinical laboratories shall not, directly or |
11 | | indirectly,
charge, bill, or otherwise solicit payment for |
12 | | anatomic pathology services unless
the services were rendered |
13 | | by the clinical laboratory or by the laboratory's employee or |
14 | | agent in accordance with Section 353 of the
Public Health |
15 | | Service Act (42 U.S.C. 263a). |
16 | | (c) No patient, insurer, third-party payor, hospital, |
17 | | public health clinic, or nonprofit
health clinic shall be |
18 | | required to reimburse any clinical laboratory for charges or
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19 | | claims submitted in violation of this Section. |
20 | | (d) Nothing in this Section shall be construed to mandate |
21 | | the assignment of benefits
for anatomic pathology services as |
22 | | defined in this Section. |
23 | | (e) For purposes of this Section, the term "anatomic |
24 | | pathology services" means: |
25 | | (1) histopathology or surgical pathology, meaning the |
26 | | gross and microscopic
examination performed by a physician |
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1 | | or under the supervision of a physician,
including |
2 | | histologic processing; |
3 | | (2) cytopathology, meaning the microscopic examination |
4 | | of cells from the
following: (i) fluids, (ii) aspirates, |
5 | | (iii) washings, (iv) brushings, or (v) smears,
including |
6 | | the Pap test examination performed by a physician or under |
7 | | the
supervision of a physician; |
8 | | (3) hematology, meaning the microscopic evaluation of |
9 | | bone marrow aspirates
and biopsies performed by a |
10 | | physician, or under the supervision of a physician, and
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11 | | peripheral blood smears when the attending or treating |
12 | | physician or technologist
requests that a blood smear be |
13 | | reviewed by a pathologist; |
14 | | (4) sub-cellular pathology or molecular pathology, |
15 | | meaning the assessment of a
patient specimen for the |
16 | | detection, localization, measurement, or analysis of one |
17 | | or
more protein or nucleic acid targets; and |
18 | | (5) blood-banking services performed by pathologists. |
19 | | (f) The provisions of this Section do not prohibit billing |
20 | | of a referring laboratory for
anatomic pathology services in |
21 | | instances where a sample or samples must be sent
to another |
22 | | laboratory for consultation or histologic processing. For |
23 | | purposes of this subsection (f), the term "referring |
24 | | laboratory" does not
include a laboratory of a physician's |
25 | | office or group practice that does not perform
the professional |
26 | | component of the anatomic pathology service involved. |
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1 | | (g) The Department may revoke, suspend, or
deny renewal of |
2 | | the license of any clinical laboratory who violates the |
3 | | provisions of this
Section. |
4 | | (h) A person who receives a bill for an anatomic pathology |
5 | | service made in
knowing and willful violation of this Section |
6 | | may maintain an action to recover the
actual amount paid for |
7 | | the bill. |
8 | | (i) This Section does not prohibit a referring physician |
9 | | who takes a patient specimen from charging a patient or a payor |
10 | | an acquisition or processing charge when: |
11 | | (1) the charge is limited to actual costs incurred for |
12 | | specimen collection and transportation; and |
13 | | (2) the charge is separately coded or denoted as a |
14 | | service distinct from the performance of the anatomic |
15 | | pathology service, in conformance with the coding policies |
16 | | of the American Medical Association. |
17 | | (j) Nothing in this Section shall be construed to prohibit |
18 | | a referring physician from sending a patient's specimen to any |
19 | | laboratory providing anatomic pathology services. |
20 | | (k) This Section does not apply to facilities licensed |
21 | | under the Hospital Licensing Act or the University of Illinois |
22 | | Hospital Act or clinical laboratories owned, operated by, or |
23 | | operated within facilities licensed under the Hospital |
24 | | Licensing Act or the University of Illinois Hospital Act, when |
25 | | billing: |
26 | | (1) for inpatient services or outpatient services from |
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1 | | those facilities; or |
2 | | (2) any other facility licensed under the Hospital |
3 | | Licensing Act or University of Illinois Hospital Act. |
4 | | (l) A physician who orders and who does not perform a |
5 | | component of anatomic pathology services shall notify in |
6 | | writing a clinical laboratory or physician who performs or |
7 | | supervises those services for a patient that the laboratory |
8 | | performing the services is not participating in the patient's |
9 | | insurance or third-party payor network. |
10 | | (m) When a physician or laboratory receives written |
11 | | notification as provided under subsection (l), notwithstanding |
12 | | the prohibitions of this Section, the laboratory or physician |
13 | | providing the anatomic pathology service shall bill the |
14 | | physician that refers the patient specimen. |
15 | | (n) A physician that receives a bill for services in |
16 | | accordance with subsection (m) may bill an insurer or other |
17 | | third-party payor, provided that: |
18 | | (1) the physician discloses in a bill for the services |
19 | | presented to insurer or other third-party payor: |
20 | | (A) the name and address of the physician or |
21 | | laboratory
that provided the anatomic pathology |
22 | | service; and |
23 | | (B) the actual amount paid or to be paid for each |
24 | | anatomic pathology service provided to the patient by |
25 | | the physician or laboratory that performed the |
26 | | service; |
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1 | | (2) the bill for anatomic pathology services is not |
2 | | directly or indirectly increased from the amount required |
3 | | to be disclosed under subparagraph (B) of paragraph (1) of |
4 | | this subsection (n) in any bill presented to the |
5 | | third-party payor; and |
6 | | (3) the billing by a referring physician as provided |
7 | | under subsection (m) is not contrary to the terms, |
8 | | contract, or policies upon which the insurer or other |
9 | | third-party payor provides payment to the billing |
10 | | physician. |
11 | | Section 10. The Medical Practice Act of 1987 is amended by |
12 | | adding Section 70 as follows: |
13 | | (225 ILCS 60/70 new) |
14 | | Sec. 70. Direct billing of anatomic pathology services. |
15 | | (a) A physician that provides anatomic pathology services |
16 | | for patients in this State shall present or
cause to be |
17 | | presented a claim, bill, or demand for payment for these |
18 | | services only to: |
19 | | (1) the patient directly; |
20 | | (2) the responsible insurer or other third-party |
21 | | payor; |
22 | | (3) the hospital, public health clinic, or nonprofit |
23 | | health clinic ordering such
services; |
24 | | (4) the referring laboratory, excluding a laboratory |
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1 | | of a physician's office or group
practice that does not |
2 | | perform the professional component of the anatomic
|
3 | | pathology service for which the claim, bill, or demand is |
4 | | presented; |
5 | | (5) governmental agencies, specified public or private |
6 | | agents of government agencies, or
organizations, working |
7 | | on behalf of the recipient of the services. |
8 | | (b) Except for a physician at a referring laboratory that |
9 | | has been billed pursuant to
subsection (f), physicians shall |
10 | | not, directly or indirectly,
charge, bill, or otherwise solicit |
11 | | payment for anatomic pathology services unless
the services |
12 | | were rendered personally by the physician or under the
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13 | | physician's direct supervision in accordance with Section 353 |
14 | | of the
Public Health Service Act (42 U.S.C. 263a). |
15 | | (c) No patient, insurer, third-party payor, hospital, |
16 | | public health clinic, or nonprofit
health clinic shall be |
17 | | required to reimburse any physician for charges or
claims |
18 | | submitted in violation of this Section. |
19 | | (d) Nothing in this Section shall be construed to mandate |
20 | | the assignment of benefits
for anatomic pathology services as |
21 | | defined in this Section. |
22 | | (e) For purposes of this Section, the term "anatomic |
23 | | pathology services" means: |
24 | | (1) histopathology or surgical pathology, meaning the |
25 | | gross and microscopic
examination performed by a physician |
26 | | or under the supervision of a physician,
including |
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| | 09800SB1630sam003 | - 8 - | LRB098 08625 MGM 44294 a |
|
|
1 | | histologic processing; |
2 | | (2) cytopathology, meaning the microscopic examination |
3 | | of cells from the
following: (i) fluids, (ii) aspirates, |
4 | | (iii) washings, (iv) brushings, or (v) smears,
including |
5 | | the Pap test examination performed by a physician or under |
6 | | the
supervision of a physician; |
7 | | (3) hematology, meaning the microscopic evaluation of |
8 | | bone marrow aspirates
and biopsies performed by a |
9 | | physician, or under the supervision of a physician, and
|
10 | | peripheral blood smears when the attending or treating |
11 | | physician or technologist
requests that a blood smear be |
12 | | reviewed by a pathologist; |
13 | | (4) sub-cellular pathology or molecular pathology, |
14 | | meaning the assessment of a
patient specimen for the |
15 | | detection, localization, measurement, or analysis of one |
16 | | or
more protein or nucleic acid targets; and |
17 | | (5) blood-banking services performed by pathologists. |
18 | | (f) The provisions of this Section do not prohibit billing |
19 | | of a referring laboratory for
anatomic pathology services in |
20 | | instances where a sample or samples must be sent
to another |
21 | | physician or laboratory for consultation or histologic |
22 | | processing. For purposes of this subsection (f), the term |
23 | | "referring laboratory" does not
include a laboratory of a |
24 | | physician's office or group practice that does not perform
the |
25 | | professional component of the anatomic pathology service |
26 | | involved. |
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| | 09800SB1630sam003 | - 9 - | LRB098 08625 MGM 44294 a |
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1 | | (g) The Department may revoke, suspend, or
deny renewal of |
2 | | the license of any physician who violates the provisions of |
3 | | this
Section. |
4 | | (h) A person who receives a bill for an anatomic pathology |
5 | | service made in
knowing and willful violation of this Section |
6 | | may maintain an action to recover the
actual amount paid for |
7 | | the bill. |
8 | | (i) This Section does not prohibit a referring physician |
9 | | who takes a patient specimen from charging a patient or a payor |
10 | | an acquisition or processing charge when: |
11 | | (1) the charge is limited to actual costs incurred for |
12 | | specimen collection and transportation; and |
13 | | (2) the charge is separately coded or denoted as a |
14 | | service distinct from the performance of the anatomic |
15 | | pathology service, in conformance with the coding policies |
16 | | of the American Medical Association. |
17 | | (j) Nothing in this Section shall be construed to prohibit |
18 | | a referring physician from sending a patient's specimen to any |
19 | | laboratory providing anatomic pathology services. |
20 | | (k) A physician who orders and who does not perform a |
21 | | component of anatomic pathology services shall notify in |
22 | | writing a clinical laboratory or physician who performs or |
23 | | supervises those services for a patient that the laboratory |
24 | | performing the services is not participating in the patient's |
25 | | insurance or third-party payor network. |
26 | | (l) When a physician or laboratory receives written |
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| | 09800SB1630sam003 | - 10 - | LRB098 08625 MGM 44294 a |
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1 | | notification as provided under subsection (k), notwithstanding |
2 | | the prohibitions of this Section, the laboratory or physician |
3 | | providing the anatomic pathology service shall bill the |
4 | | physician that refers the patient specimen. |
5 | | (m) A physician that receives a bill for services in |
6 | | accordance with subsection (l) may bill an insurer or other |
7 | | third-party payor, provided that: |
8 | | (1) the physician discloses in a bill for the services |
9 | | presented to insurer, or other third-party payor: |
10 | | (A) the name and address of the physician or |
11 | | laboratory
that provided the anatomic pathology |
12 | | service; and |
13 | | (B) the actual amount paid or to be paid for each |
14 | | anatomic pathology service provided to the patient by |
15 | | the physician or laboratory that performed the |
16 | | service; |
17 | | (2) the bill for anatomic pathology services is not |
18 | | directly or indirectly increased from the amount required |
19 | | to be disclosed under subparagraph (B) of paragraph (1) of |
20 | | this subsection (m) in any bill presented to the |
21 | | third-party payor; and |
22 | | (3) the billing by a referring physician as provided |
23 | | under subsection (l) is not contrary to the terms, |
24 | | contract, or policies upon which the insurer or other |
25 | | third-party payor provides payment to the billing |
26 | | physician.
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