Commercial Insurance Plans following the TC Grandfather Changes

May 13, 2013

We have found that some independent labs are now seeing commercial payers applying the TC (technical component) Grandfather Clause and the non-payment of the technical component of hospital inpatients and outpatient to these labs. The payers are now using the exact same reasoning as Medicare which presumes the payment for the TC is paid via a DRG, therefore the payer does not need to pay the technical component portion of this global bill.  Some payers are actually quoting the Medicare regulations as their reasoning to deny these claims.  How do you fix this? First, you need to review your contract; this change may not be covered by the current contract.  Second, you need to open up discussions with the payers to educate them on this process and the fact that you are actually performing this work.

The other option is that you could go back to the hospital for pass through compensation for this work; again this will lead to a series of conversations.  Be advised that the hospital administrators will be blindsided by this request for more cash.

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