Sen. William R. Haine

Filed: 4/12/2013

 

 


 

 


 
09800SB1630sam003LRB098 08625 MGM 44294 a

1
AMENDMENT TO SENATE BILL 1630

2    AMENDMENT NO. ______. Amend Senate Bill 1630, AS AMENDED,
3by replacing everything after the enacting clause with the
4following:
 
5    "Section 5. The Illinois Clinical Laboratory and Blood Bank
6Act 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
10services for patients in this State shall present or cause to
11be presented a claim, bill, or demand for payment for these
12services 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

 

 

09800SB1630sam003- 2 -LRB098 08625 MGM 44294 a

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
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
11indirectly, charge, bill, or otherwise solicit payment for
12anatomic pathology services unless the services were rendered
13by the clinical laboratory or by the laboratory's employee or
14agent in accordance with Section 353 of the Public Health
15Service Act (42 U.S.C. 263a).
16    (c) No patient, insurer, third-party payor, hospital,
17public health clinic, or nonprofit health clinic shall be
18required to reimburse any clinical laboratory for charges or
19claims submitted in violation of this Section.
20    (d) Nothing in this Section shall be construed to mandate
21the assignment of benefits for anatomic pathology services as
22defined in this Section.
23    (e) For purposes of this Section, the term "anatomic
24pathology services" means:
25        (1) histopathology or surgical pathology, meaning the
26    gross and microscopic examination performed by a physician

 

 

09800SB1630sam003- 3 -LRB098 08625 MGM 44294 a

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
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
20of a referring laboratory for anatomic pathology services in
21instances where a sample or samples must be sent to another
22laboratory for consultation or histologic processing. For
23purposes of this subsection (f), the term "referring
24laboratory" does not include a laboratory of a physician's
25office or group practice that does not perform the professional
26component of the anatomic pathology service involved.

 

 

09800SB1630sam003- 4 -LRB098 08625 MGM 44294 a

1    (g) The Department may revoke, suspend, or deny renewal of
2the license of any clinical laboratory who violates the
3provisions of this Section.
4    (h) A person who receives a bill for an anatomic pathology
5service made in knowing and willful violation of this Section
6may maintain an action to recover the actual amount paid for
7the bill.
8    (i) This Section does not prohibit a referring physician
9who takes a patient specimen from charging a patient or a payor
10an 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
18a referring physician from sending a patient's specimen to any
19laboratory providing anatomic pathology services.
20    (k) This Section does not apply to facilities licensed
21under the Hospital Licensing Act or the University of Illinois
22Hospital Act or clinical laboratories owned, operated by, or
23operated within facilities licensed under the Hospital
24Licensing Act or the University of Illinois Hospital Act, when
25billing:
26        (1) for inpatient services or outpatient services from

 

 

09800SB1630sam003- 5 -LRB098 08625 MGM 44294 a

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
5component of anatomic pathology services shall notify in
6writing a clinical laboratory or physician who performs or
7supervises those services for a patient that the laboratory
8performing the services is not participating in the patient's
9insurance or third-party payor network.
10    (m) When a physician or laboratory receives written
11notification as provided under subsection (l), notwithstanding
12the prohibitions of this Section, the laboratory or physician
13providing the anatomic pathology service shall bill the
14physician that refers the patient specimen.
15    (n) A physician that receives a bill for services in
16accordance with subsection (m) may bill an insurer or other
17third-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;

 

 

09800SB1630sam003- 6 -LRB098 08625 MGM 44294 a

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
12adding 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
16for patients in this State shall present or cause to be
17presented a claim, bill, or demand for payment for these
18services 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

 

 

09800SB1630sam003- 7 -LRB098 08625 MGM 44294 a

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
9has been billed pursuant to subsection (f), physicians shall
10not, directly or indirectly, charge, bill, or otherwise solicit
11payment for anatomic pathology services unless the services
12were rendered personally by the physician or under the
13physician's direct supervision in accordance with Section 353
14of the Public Health Service Act (42 U.S.C. 263a).
15    (c) No patient, insurer, third-party payor, hospital,
16public health clinic, or nonprofit health clinic shall be
17required to reimburse any physician for charges or claims
18submitted in violation of this Section.
19    (d) Nothing in this Section shall be construed to mandate
20the assignment of benefits for anatomic pathology services as
21defined in this Section.
22    (e) For purposes of this Section, the term "anatomic
23pathology 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

 

 

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
19of a referring laboratory for anatomic pathology services in
20instances where a sample or samples must be sent to another
21physician or laboratory for consultation or histologic
22processing. For purposes of this subsection (f), the term
23"referring laboratory" does not include a laboratory of a
24physician's office or group practice that does not perform the
25professional component of the anatomic pathology service
26involved.

 

 

09800SB1630sam003- 9 -LRB098 08625 MGM 44294 a

1    (g) The Department may revoke, suspend, or deny renewal of
2the license of any physician who violates the provisions of
3this Section.
4    (h) A person who receives a bill for an anatomic pathology
5service made in knowing and willful violation of this Section
6may maintain an action to recover the actual amount paid for
7the bill.
8    (i) This Section does not prohibit a referring physician
9who takes a patient specimen from charging a patient or a payor
10an 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
18a referring physician from sending a patient's specimen to any
19laboratory providing anatomic pathology services.
20    (k) A physician who orders and who does not perform a
21component of anatomic pathology services shall notify in
22writing a clinical laboratory or physician who performs or
23supervises those services for a patient that the laboratory
24performing the services is not participating in the patient's
25insurance or third-party payor network.
26    (l) When a physician or laboratory receives written

 

 

09800SB1630sam003- 10 -LRB098 08625 MGM 44294 a

1notification as provided under subsection (k), notwithstanding
2the prohibitions of this Section, the laboratory or physician
3providing the anatomic pathology service shall bill the
4physician that refers the patient specimen.
5    (m) A physician that receives a bill for services in
6accordance with subsection (l) may bill an insurer or other
7third-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.
 

 

 

09800SB1630sam003- 11 -LRB098 08625 MGM 44294 a

1    Section 99. Effective date. This Act takes effect December
231, 2013.".