Egregious Charges for Blood Collection/Venipuncture Services
Background
ClaimDOC’s comprehensive line-by-line auditing of claims uncovers errors that basic claim repricing and auto-adjudication do not catch, leading to greater savings for health plans and its plan members. Our audit team analyzes all types of healthcare claims for a variety of potential concerns, including excessive usual and customary charges, duplication of claims, incorrect coding/billing, unbundling of services, and many others. Our claims review is not intended to impact care decisions or medical practice.
In this Audit Spotlight, we focus on claim examples where the provider reported and billed blood collection/venipuncture services.
We asked three (3) questions:
- Is the provider really charging this much for a blood collection/venipuncture service (CPT code 36415)?
- Is this a billing error?
- Is the provider’s charge egregious for the type of service provided and billed?
CPT code 36415 is defined as the collection of venous blood by venipuncture. In this procedure, usually, a lab technician and/or other individual inserts a needle into the vein to collect a blood sample, most commonly for laboratory testing. This procedure includes all venipunctures performed on superficial peripheral veins of the upper and lower extremities and does not require the skills of a physician for specimen collection.
Depending on where the blood collection/venipuncture is performed, the service may be billed by a variety of providers in different places of service. For example, blood collection/venipuncture services can be reported/billed with place of service Office (11), home (12), assisted living (13), mobile unit (15), urgent care (20), inpatient hospital (21), outpatient hospital (22) emergency room (23), skilled nursing facility (31) nursing facility (32), and clinic (49). Hospitals can bill for blood collection/venipuncture services on inpatient and outpatient hospital claims and clinical laboratory entities can bill/report blood collection/venipuncture services.
Case Scenarios
Case One
A 46-year-old female was seen/treated at a hospital in New Jersey.
Hospital charge for CPT code 36415 – $341.00.
New Jersey hospital’s cost for CPT code 36415 – $11.66
Case Two
A 62-year-old male was seen/treated at a hospital in Florida.
Hospital charge for CPT code 36415 – $182.00
Florida hospital’s cost for CPT code 36415 – $2.59
According to FAIRHealth® data, depending on the locality where services are performed/zip code, a provider charge for CPT code 36415 can range from $15.00 – $40.00 for this service.
Based on ClaimDOC 2023 claims data, the average provider charge for CPT code 36415 is $23.72.
The lowest charge billed for CPT code 36415 is $2.36, reported/billed by a clinical laboratory company.
The Takeaway
How do costs relate to the “charge,” or the “price,” that health care providers put on the bill/claim? Unfortunately, there is often no clear relationship.
How can a hospital charge $341.00 for CPT code 36415 and a clinical laboratory company charge $2.36 for the exact same service?
Concerns of egregious charges for a frequently reported/billed service -blood collection/venipuncture (CPT code 36415) is evident on provider claims. While providers can charge any amount they elect for services, egregious fees and billing/coding errors complicate matters for members to understand their bills and payments, impact the collection of patient balances, build a reputation of physicians charging high fees, create burdens for patients having no insurance and a host of others.
Obtaining pricing estimates prior to needing or having related care to understand how much one is obligated to pay for their services and learning if there are any coverage limitations can be beneficial to avoid surprise medical bills. Whenever an individual receives a bill and the cost for care seems inappropriate/questionable, an inquiry to the provider and/or health plan should be made to obtain an explanation of the service(s) and corresponding charge(s).
Our goal at ClaimDOC is to use benchmark charges and costs nationally to negotiate fair and ethical payments. Employers turn to us to establish fair reimbursement rates for their plans, allowing them to save money and provide richer benefits to their employees. A win-win for everyone.