Some insurers failing to follow billing guidelines for COVID-19 tests

By John McPhaul

The Association of Clinical Laboratories announced on Thursday that it has filed a formal complaint with Puerto Rico’s insurance commissioner over the failure of some insurers to follow the guidelines for billing, fees and payments for COVID-19 tests as established by the United States Department of Health and Human Services and the Center for Medicaid and Medicare Services (CMS by its Spanish initials).

“The Normative Letter of the Office of the Insurance Commissioner [OCS by its Spanish initials] CN-2050-265-D, obliges all health service organizations and insurers that sign commercial medical plans to extend to their beneficiaries coverage that guarantees access to the medical and health services that are necessary in the context of the current pandemic,” Association President Juan Rexach said in a written statement. “This measure is undoubtedly a timely and necessary one. However, we believe that an additional directive is also necessary in accordance with the recent guidelines issued by the CMS.”

On April 14, the CMS issued a regulatory letter (CMS-Ruling 2020-1-R) to promote a new rate incorporated into the Clinical Laboratory Fee Schedule.

The new rate, which was increased for Medicare Part B patients, is payable for certain tests linked to COVID-19. Among the reasons that motivated the fees revision are the costs involved in administering the tests, the sophistication that specimen processing requires from clinical laboratories, and other factors of an operational nature.

However, most of the island’s private insurers chose to use the impositions of the Health Insurance Administration (ASES by its Spanish acronym) as a government guide to establish the billing codes and the rates payable to providers, in contravention of those established by CMS. On April 21, ASES established fee guidelines and billing codes in relation to the taking of samples and the different tests that are administered for the detection of COVID-19. That determination governs the Puerto Rico government health plan.

“The billing codes adopted by ASES, and the corresponding rates, were established in an improvised manner, without any cost study, and they are also significantly lower than those established by CMS for the Medicare and Medicaid programs,” reads the Association of Clinical Laboratories’ complaint sent to the OCS. “Payments to providers under this rate scheme do not allow them to even meet the costs related to the administration of the tests and the costs associated with the provision of the service, such as compliance with the parameters dictated by the island Labor [and Human Resources] Department, its specialized PR OSHA [Occupational Safety and Health Administration] office, the [Puerto Rico] Department of Health, and many other challenges exacerbated by the pandemic.”

“We believe that both ASES and the OCS must locally adopt the same reasoning of the CMS,” Rexach said. “The challenges and complexities that motivated CMS to adopt a rate increase are the same faced by clinical laboratories in Puerto Rico, in all areas of their operation, regardless of the line of business in question.”

According to the complaint filed, the Association of Clinical Laboratories requests that the OCS order insurers to cease and desist from their practices of unilaterally amending the contracts signed with their suppliers and imposing non-negotiated rates. In addition, it requests action to standardize the billing and payment process for all insurers.

The defendant parties, as established in the legal document, are: Triple-S Salud Inc., Triple-S Advantage Inc., MMM Health Care LLC, MSO of Puerto Rico LLC, MMM Multi Health LLC, MCS Life Insurance Co. Inc., MCS Advantage Inc., MAPFRE Life Insurance Co. of Puerto Rico, International Medical Card Inc., First Medical Health Plan Inc., and Humana Health Plans of Puerto Rico.

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