iBoske | Compliance/Revenue Guidelines

Create a Decision Tree

Sam Carpenter

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Is the patient Medicare. Yes. Any other Payor.
Patient Status Whn Sample Originally Collected (Patient has to be discharged). Inpatient. Hospital Outpatient.
Date Ordered by Provider after Discharge. Less than 14 days of discharge. 14-30 days. > 30 days .
Date of Service becomes:. Original Collection Date.
Who is required/allowed to bill for the testing? Hospital REQUIRED to bill Medicare.
Is the Reference Lab willing to bill patient directly? Hospital REQUIRED to bill patient. Ref Lab must bill SHMC.
Proceed to next steps? Proceed.
Decision Point: Responsible Billing Party (Hospital or Patient). Bill Hospital/Client (SHMC).
*Order in Cerner *RedCap Misc Sendouts *Use original EPIC Registration.
Date of Service becomes:. Date the Test is Performed.
Who is Required or Allowed to Bill for the Testing? Reference Lab Allowed to Bill the Patient's Insurance.
Is the Reference Lab Willing to Bill Patient Insurance Directly? Yes. Yes, but req is marked bill SHMC. No.
Steps:. Move onto Next Steps.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Patient Insurance.
*RedCap Pass Through Sendouts.
Steps:. *Send test out, mark req. "Bill SHMC/Client" *Send paperwork for UM tracking.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Hospital/Client (SHMC).
*Order in Cerner *RedCap Misc Sendouts *Follow DOS Rules.
Steps:. *Send test out, mark req. "Bill SHMC/Client" *Send paperwork for UM tracking.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Hospital/Client (SHMC).
*Order in Cerner *RedCap Misc Sendouts *Follow DOS Rules.
Date of Service Becomes? Date pulled from Archive.
Who is Required or Allowed to Bill for the Testing? Reference Lab Allowed to Bill the Patient's Insurance.
Reference Lab Allowed to Bill the Patient's Insurance? Yes. Yes, but req is marked bill SHMC. No.
Steps:. Move onto Next Steps.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Patient Insurance.
*RedCap Pass Through Sendouts.
Steps:. *Send test out, mark req. "Bill SHMC/Client" *Send paperwork for UM tracking.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Hospital/Client (SHMC).
* Order in Cerner *RedCap Misc Sendouts Tracking *Follow DOS Rule Chart.
Steps:. *Send test out, mark req. "Bill SHMC/Client" *Send paperwork for UM tracking.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Hospital/Client (SHMC).
* Order in Cerner *RedCap Misc Sendouts Tracking *Follow DOS Rule Chart.
Date Provider Ordered Test (Actual Date on Order). Any date after hospital discharge.
Date of Service becomes:. Date the test is performed.
Who is required/allowed to bill for the testing? Reference Lab REQUIRED to bill the patient's insurance.
Is the Reference Lab willing to bill patient directly? Yes. No.
Proceed to next Steps? Proceed.
Decision Point Responsible Billing Party (Hospital or Patient). Bill patient insurance.
*RedCap Pass Through Sendouts.
Hard Stop. * Order Misc. test in Cerner with Order Note "Ref. Lab refuses to Bill" * Send paperwork for UM tracking.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Hospital/Client (SHMC).
* Order in Cerner *RedCap Misc Sendouts Tracking *Follow DOS Rule Chart.
Patient Status. Inpatient, Hospital Outpatient, OP Non-patient, Specimen.
Date Provider Ordered Test (Actual Date on Order). Any date after discharge.
Date of Service becomes:. Dependent on billing party (proceed).
Who is required/allowed to bill for the testing? Reference Lab Allowed to bill patient's insurance.
Is the Reference Lab willing to bill patient directly? Yes. Yes, but Ref Lab Test Requisition is marked to bill SHMC. No.
Proceed to next Steps? Proceed.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Patient Insurance.
*RedCap Pass Through Sendouts.
Proceed to next steps? *Send test out, and mark requisition to "Bill SHMC/Client" *Send paperwork to Sendouts Supervisor for UM tracking.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Hospital/Client (SHMC).
* Order in Cerner *RedCap Misc Sendouts Tracking *Follow DOS Rule Chart.
Proceed to next steps? 1) Send test out, and mark requisition to "Bill SHMC/Client" 2) Send paperwork to Sendouts Supervisor for UM Tracking.
Decision Point Responsible Billing Party (Hospital or Patient). Bill Hospital/Client (SHMC).
* Order in Cerner *RedCap Misc Sendouts Tracking *Follow DOS Rule Chart.