Are Clinical Laboratories Prepared to Cope with Outrage Over Surprise Laboratory Medical Billing Services?
Patient Access Management may be an effective solution!
Consumer demand and federal requirements for price transparency affect how clinical laboratories and anatomic pathology groups meet patient expectations while navigating complex payer agreements.
Regardless of a clinical laboratory’s payer mix and RCM system, the demand for greater price transparency impacts laboratory medical billing services just as it does other healthcare services. Addressing new federal policies that support price transparency may require laboratory owners to alter how they approach RCM and patient communication.
Patient access management (PAM) is what some early-adopter medical labs and pathology groups are using to respond to these new federal policies and changing patient expectations. PAM can be an effective tool to fulfill complex payer requirements and implement consumer-friendly laboratory medical billing services. Not only does this comply with federal guidelines, but it also helps independent laboratories increase revenue by lowering denial rates.
How and When Clinical Laboratories Should Implement Patient Access Management
Revenue cycle experts say clinical laboratories are in a position to take an active role in the pricing transparency debate.
“If labs don’t control the pricing narrative, someone else will,” stated Walt Williams, Director of Revenue Cycle Optimization and Strategy for Quadax, a firm that has studied revenue trends in healthcare for more than 40 years.
He says, given these new demands in clinical laboratories and pathology groups, facilitating efficient Laboratory Medical Billing Services ensures a satisfactory patient and physician experience and reduces the financial risk related to trends in uncollected revenue.
“In this age of increasing consumerism—along with the complex challenges of navigating the payer landscape and pre-empting administrative denials—it’s no wonder independent labs are turning to new patient access technology solutions to avoid leaving money on the table,” Williams said.
Patient access management solutions allow clinical laboratories to:
- obtain accurate patient demographic information,
- verify insurance coverage and eligibility, and
- gain clarity on payer rules regarding prior authorization and medical necessity.
These capabilities enable medical laboratories to secure appropriate reimbursement closer to the date of service. PAM also can provide the ordering-physician with financial counseling and guidelines on a patient’s financial obligation. This is shared with the patient to help prevent surprise billing.
A New Fact for Labs: Patients are the New Payers
Laboratory Medical Billing Services patient-access representatives must employ proper patient-liability collection techniques before, during, and after each date of service. This has become increasingly challenging as more patients join high-deductible health plans (HDHPs) and take on more financial responsibility. The problem for labs is that meeting the expectations of consumers requires a different toolset than meeting the needs of complex payer requirements.
Additionally, evolving policies in prior authorization, medical necessity, and coding are resulting in potential payment traps for patients and known revenue traps for providers and suppliers.
While the current high cost of Laboratory Medical Billing Services will likely continue for some time, publishing information about the lab’s policies can help consumers view choices when it comes to selecting laboratory tests and anticipating potential payment obligations.
Henry Ford Health System, for example, posted information about prior authorization as it relates to its pathology and laboratory services.
Consumer-Facing Price Transparency and CMS Requirements
Rooted in price transparency regulations issued in July 2018, the Federal Centers for Medicare and Medicaid Services (CMS) encouraged all providers and suppliers of healthcare services to undertake efforts to engage in consumer-friendly communication of their charges, helping patients understand what their potential financial liability might be for services they obtain, and to enable them to compare charges for similar services. We encourage providers and suppliers to update this information at least annually, or more often as appropriate, to reflect current charges.”
The questions below, which CMS posed for comment in “Hospital Outpatient Prospective Payment-Notice of Proposed Rulemaking” (CMS-1695-P), may help lab managers tasked with making price transparency program decisions. They include:
- How should we define “Standard Charges” in provider and supplier settings? Is the best measure of a provider’s or supplier’s standard charges, its chargemaster, price list, or charge list?
- What types of information would be most beneficial to patients? Enable patients to use charge and cost information in their decision-making?
- How can information on out-of-pocket costs be provided to better support patient choice and decision-making? What can be done to better inform patients of their financial obligations?
- What changes would need to be made by providers and suppliers to provide patients with information on what Medicare pays for a particular service performed by that provider or supplier?
These considerations and more can help the development of patient access management and consumer-friendly communication initiatives that are tailored to clinical laboratory services.
Patient Access Management for Clinical Laboratories
Patient access management facilitates critical components of the revenue cycle. However, it must be fine-tuned to fit each healthcare provider’s unique revenue cycle process. This includes clinical laboratory and anatomic pathology services.
“Having business rules and workflows based on best practices to verify patient demographics, support insurance discovery, and navigate prior authorizations are now a minimum requirement for any healthcare provider to maintain financial viability,” Williams notes.
Bikham Healthcare helps laboratory owners manage their laboratory medical billing services effectively, and realize revenue goals easily. Outsource laboratory billing services to Bikham today and witness the rise in your collection numbers.