§ 10-16-138 — Pathology services - direct billing required

Colorado § 10-16-138

• Jurisdiction: Colorado
• Title 10: Insurance
• Art.: Health-care Coverage

Text

(1) A clinical
laboratory or physician that is located in this state or in another state, and that
provides anatomic pathology services for patients in this state, shall present or
cause to be presented a claim, bill, or demand for payment for these services only
to:

(a) The patient;

(b) The responsible insurance carrier or other third-party payer;

(c) The hospital, public health clinic, or nonprofit health clinic ordering such
services;

(d) The referring laboratory, excluding a laboratory of a physician's office or
group practice that does not perform the professional component of the anatomic
pathology service for which such claim, bill, or demand is presented; or

(e) A governmental agency or its specified public or private agent, agency, or
organization on behalf of the recipient of the services.

(2) Except for a physician at a referring laboratory that has been billed
pursuant to subsection (6) of this section, no licensed practitioner in the state may,
directly or indirectly, charge, bill, or otherwise solicit payment for anatomic
pathology services unless the services were rendered personally by the licensed
practitioner or under the licensed practitioner's direct supervision in accordance
with section 353 of the Public Health Service Act, 42 U.S.C. sec. 263a.

(3) A patient, insurer, third-party payer, hospital, public health clinic, or
nonprofit health clinic is not required to reimburse a licensed practitioner for
charges or claims submitted in violation of this section.

(4) Nothing in this section:

(a) Mandates the assignment of benefits for anatomic pathology services; or

(b) Prohibits a group practice, as defined in 42 U.S.C. sec. 1395nn (h)(4)(A)(i)
to (iv), from billing for anatomic pathology services when a physician in the group
practice performs or supervises anatomic pathology services in a laboratory that is
owned and operated by at least one member of the group practice.

(5) For purposes of this section, anatomic pathology services means:

(a) Histopathology or surgical pathology, meaning the gross and microscopic
examination performed by a physician or under the supervision of a physician,
including histologic processing;

(b) Cytopathology, meaning the microscopic examination of cells from the
following:

(I) Fluids;

(II) Aspirates;

(III) Washings;

(IV) Brushings; or

(V) Smears, including the pap test examination performed by a physician or
under the supervision of a physician;

(c) Hematology, meaning the microscopic evaluation of bone marrow
aspirates and biopsies performed by a physician, or under the supervision of a
physician, and peripheral blood smears when the attending or treating physician or
technologist requests that a blood smear be reviewed by a pathologist;

(d) Subcellular pathology or molecular pathology, meaning the assessment
of a patient specimen for the detection, localization, measurement, or analysis of
one or more protein or nucleic acid targets; and

(e) Blood-banking services performed by pathologists.

(6) This section does not prohibit billing of a referring laboratory for
anatomic pathology services in instances where a sample or samples must be sent
to another physician or laboratory for consultation or histologic processing. The
term referring laboratory does not include a laboratory of a physician's office or
group practice that does not perform the professional component of the anatomic
pathology service involved.

(7) A person who receives a bill for an anatomic pathology service made in
knowing and willful violation of this section may maintain an action to recover the
actual amount paid for the bill.

Legislative History

Source: L. 2012: Entire section added, (HB 12-1221), ch. 41, p. 142, � 1, effective January 1, 2013.