Presenting claim for payment for anatomic pathology services
Section 225. (a) For the purposes of this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:
“Anatomic pathology service”, histopathology, surgical pathology, cytopathology, hematology, subcellular pathology, molecular pathology and blood-banking services performed by a pathologist.
“Charge”, the uniform price for specific services within a revenue center of a hospital.
“Cytopathology”, the examination of cells from the following:
(iv) brushings; or
(v) smears, including the pap test examination performed by a physician or under the supervision of a physician.
“Hematology”, 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.
“Histopathology” or “surgical pathology”, the gross and microscopic examination of organ tissue performed by a physician or under the supervision of a physician.
“Patient”, any natural person receiving health care services.
“Revenue center”, a functioning unit of a hospital which provides distinctive services to a patient for a charge.
“Third party payer”, an entity including, but not limited to, Title XVIII and Title XIX of the federal Social Security Act programs, other governmental payers, insurance companies, health maintenance organizations and nonprofit hospital service corporations. Third party payer shall not include a purchaser responsible for payment for health care services rendered by a hospital, either to the purchaser or to the hospital.
(b) A clinical laboratory or physician providing anatomic pathology services for patients in the commonwealth shall present or cause to be presented a claim, bill or demand for payment for these services only to the following:
(i) the patient directly;
(ii) the responsible insurer or other third-party payer;
(iii) the hospital, public health clinic or nonprofit health clinic ordering such services;
(iv) the referral laboratory or a physician’s office laboratory when the physician of such laboratory performs the anatomic pathology service; or
(v) the governmental agency or its specified public or private agent, agency or organization on behalf of the recipient of the services.
(c) Except as provided under this section, no licensed practitioner shall, 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 under section 353 of the Public Health Service Act, 42 U.S.C. § 263a.
(d) No patient, insurer, third party payer, hospital, public health clinic or non-profit health clinic shall be required to reimburse any licensed practitioner for charges or claims submitted in violation of this section.
(e) Nothing in this section shall be construed to mandate the assignment of benefits for anatomic pathology services.
(f) Nothing in this section shall prohibit billing between laboratories for anatomic pathology services in instances where a sample must be sent to another specialist. Nothing in this section shall authorize a physician’s office laboratory to bill for anatomic pathology services when the physician of such laboratory has not performed the anatomic pathology service.
(g) The board of registration in medicine may revoke, suspend or deny renewal of the license of a practitioner who violates this section.