Readers Respond

Readers Respond

Pap patient will not sign waiver

Ms. Evans: We are a reference lab and recently sent out our yearly reminder to offices that they are to only order medically necessary tests. In the verbiage that went out, it was indicated that if tests were not medically necessary, we may bill the clinic for that testing. Surprisingly, a number of office managers read that statement and are now asking questions. This one has us stumped, and I hope perhaps you could clarify this subject. This involves Pap-smear testing where the lab has no face to face with the patient; offices collect those specimens and send them to the lab with an appropriate order.

The question was, who is liable for the patient that refuses to sign a waiver if the next Pap smear comes back and she has a high-grade lesion. Medicare only pays for Paps every two years if they are for screening purposes. I understand that high-grade lesion in the cervix usually takes more time than two years to get to the point that it is cancer, but the possibility exists. This OB/GYN-office manager is concerned that the patient would sue her office, and I am sure she wants to spread that risk. Or if they go ahead and collect the Pap smear and send it our office, do we not do it?

In the past, if a patient refused to sign a waiver, we let the physician office know. It does not happen that often, but now that Medicaid programs are using the same NCDs and LCDs [local coverage determinations and national coverage determinations] that Medicare uses, we will run into that more often. When this CMS’ [Centers for Medicare and Medicaid Services’] proposal concerning physicians signing orders came up, most labs [like ours] thought [we] were morally responsible to doing the testing — even if we knew we could not or should not bill government programs for that testing. With that thought in mind, we probably would do the testing anyway.

To what extent are laboratories liable for bad patient outcomes if the patient refuses to sign these waivers? And back to blood tests [for which] patients refused to sign, we have only called the physician and let [him] know that the patient did not want to be billed for testing if diagnosis or frequency limitations were exceeded. We have not documented that in the EMR [electronic medical record], and should we be? I sort [of] feel like we are “darned if we do and darned if we don’t.” Once the resources are used to provide that answer, there is nothing to “repossess”! Where does the liability fall when a patient refuses the possibility of paying for a test, and how should that be documented in the world of EMRs? It takes a fair amount of time to register, order, label results with “patient refused,” and then credit that test(s). Is this the world we just live in now?

I am sure we are not the only lab in the country that has concerns about this. I read the “Liability and the lab” article in the MLO regularly, and if you have addressed this already, I must have missed an issue. If so, you tell me when that was addressed and I will look it up. Thank you much.

—Patricia L. Goehring, MLS(ASCP)CM


Cedar Rapids, IA

Editor’s note: Thank you for your inquiry about a seriously puzzling situation. Ober|Kaler, Ms. Evans’ employer, has directed us to other resources for this particular question. We currently are seeking a certified compliance officer who can respond most appropriately. When we receive the answer, we will send it directly to you, Patricia, then publish it in this section of the magazine.


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