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
| ||||||
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 |
| |||||||
| |||||||
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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| |||||||
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 |
| |||||||
| |||||||
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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1 | Section 99. Effective date. This Act takes effect December | ||||||
2 | 31, 2013.".
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