Genova Diagnostics is a participant in the Medicare program. Genova Diagnostics will bill Medicare directly for the patient provided:
- The test is medically necessary and billable to Medicare.
- The health care practitioner has a valid National Provider Identification (NPI) number. Please note, if the health care practitioner is not qualified under the Medicare program to order or refer laboratory services the patient will be financially responsible for the charges.
- A completed requisition is received with valid ICD-9 diagnosis coding and a copy of the patient's Medicare card.
Genova Diagnostics bills Medicare for all tests except those determined by Medicare as not billable to Medicare. A list of these tests can be obtained by calling Genova Diagnostics. Medicare patients may choose the prepay (see the "Patient Prepayment" section) when:
- If the test is likely to be denied by Medicare and the patient chooses option two on the Advanced Beneficiary Notice.
- The test is determined by Medicare as not billable to Medicare.
- The health care practitioner is not qualified under the Medicare program.
Medicare policy requires that the patient be given a Medicare form called an Advanced Beneficiary Notice (ABN) for certain tests. The ABN is included in the kits for these tests and should be reviewed carefully by the patient.
The ABN is mandated by Medicare to:
- Advise the patient (informed consent) that the test may not be paid by Medicare;
- Allow the patient, with informed consent, to authorize the lab to perform the test and to bill Medicare, or to allow the patient to make payment at a discounted price to minimize their out of pocket expense and claim would not be filed to Medicare; and
- Allow the patient, with informed consent, to acknowledge that if Medicare doesn't pay, then the Medicare beneficiary will be financially responsible for the tests listed on the notice.
The ABN must be obtained prior to sending the test sample. To be completed properly, the ABN must have the beneficiaries name indicated at the top, must have an option indicated with a check or "x", and must be signed and dated by the patient. The ABN must be sent with the requisition and test sample. Medicare regulations require the covered party to be given a copy of the signed ABN by the physician's office.
Genova Diagnostics has taken a proactive role in Medicare Compliance. We fully support federal regulations to enforce financial and professional integrity and to ensure that tests ordered under Medicare reimbursement meet the standards of "medical necessity."
All claims submitted to Medicare for Genova Diagnostics' laboratory services must be for tests that are medically necessary. "Medically necessary" is defined as a test or procedure that is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Consequently, tests performed for screening purposes will not be reimbursed by the Medicare program. Physicians may deem it medically necessary to order a single test or a portion of a profile.
As a Medicare provider we are required to file claims to Medicare Advantage Plans on behalf of the patient and will do so without the patient's participation in our Insurance Billing program. Some Medicare Advantage plans assign substantial out of pocket expense for Genova's Services, these are typically those plans offered by the payers excluded from the Insurance Billing program. Patients covered by Medicare Advantage plans offered by these payers should carefully consider having testing performed by Genova.