Payer audits are increasing—Medicare TPEs, UPIC probes, and commercial pre-payment reviews are putting labs under more scrutiny than ever. In this 60-minute on-demand session, learn what revenue cycle leaders need to know in 2025 to reduce audit risk, spot common triggers, and respond effectively. We share real-world audit scenarios, key questions to ask your RCM vendor, and how the right partner can help protect your billing operations.
Category: For Laboratories
Discover the latest news, trends, and best practices in revenue cycle management for lab and diagnostic providers, including coding, billing, and collections.
Carelon MBM Genetic Testing Program Policy Changes Effective August 1, 2025
Carelon Medical Benefits Management (MBM) has announced updates to its Genetic Testing Program policies that will take effect on August 1, 2025. Under the new policy, the Date of Service (DOS) for genetic testing services will be defined as the sample or collection date for all lines of business, aligning with the CMS Medicare Laboratory Date of Service Policy. For archival samples—those stored for future use, analysis, or reference—the DOS will be considered the date the sample was collected or retrieved.
Providers can review the full announcement by visiting the Carelon Provider Connections page at this link. Once there, scroll to the Genetic Testing Program section and click on the article titled “Reminder: Genetic Testing Program updates coming soon.”
Laboratory providers who wish to request an exception to these policy changes may contact the Carelon MBM Genetic Testing Team by emailing DL-GeneticTestingSolution@carelon.com.
For Quadax clients, if this policy update requires a change in how service dates are handled, please consult your Quadax representative to begin planning. This may involve modifications to your billing interface with Quadax.
The Hidden Risk of a Rapid RCM Vendor Implementation
For laboratories and pathologists, a strong revenue cycle management (RCM) implementation isn’t about speed—it’s about setting up for long-term success.
Turn the Summer Slowdown into Reclaimed Revenue Potential
Why Now Is the Right Time for Labs to Reevaluate Their RCM Partner
What’s Next for LDTs? A Look Beyond the Ruling
Get the key takeaways from our expert-led webinar on the LDT final rule ruling—and why labs must stay vigilant as the story unfolds.
Beyond the LDT Ruling: Next Steps & What it Means for Your Lab
The LDT final rule was vacated on March 31. The district court judge accepted ACLA’s and AMP’s arguments that LDTs are not devices and determined that the final rule exceeded FDA’s authority. This is a huge victory for the laboratory industry, but it is not the end. What happens (or could happen) next, and what does the decision really mean for laboratories?
Overcoming Claim Denials: Effective Strategies for Prevention and Appeals Success
Claim denials are an ongoing challenge, perpetuated by the ever-changing coverage requirements imposed by insurance companies on laboratory tests. Join this insightful webinar, as we delve into the intricate philosophy behind the practice of denials from various perspectives, including those of physicians, laboratories, insurance companies, laboratory benefits managers, and patients. By examining these differing viewpoints, we can gain a comprehensive understanding of the motivations and implications of denials.
“Overcoming Claim Denials: Effective Strategies for Prevention and Appeals Success,” will present proven strategies to prevent and reduce denials, minimizing the burden on all parties. Recognizing that preventive measures may not always be feasible, or denials may be unavoidable, we explore the importance of a robust appeal process to ensure service reimbursement and patient coverage.
Decoding Claim Denials: Strategies for Prevention & Effective Appeals
Uncover the underlying causes of denials, explore proactive strategies to minimize their occurrence, and demonstrate the power of a streamlined appeals process for maximizing revenue.
Actionable Strategies to Ensure Lab Compliance for Financial Health
Protect Your Lab: Key Strategies for Compliance and Medical Necessity Adherence.
Clinical laboratories today face increased scrutiny regarding compliance and medical necessity. Our recent webinar, featuring Danielle Tangorre, a partner in Robinson & Cole LLP’s Health Law Group and Tom Cronin, SVP of Revenue Cycle Strategy & Analytics for Quadax, delved into these critical areas, offering valuable insights for laboratories seeking to maintain operational integrity.
The presentation emphasized that a robust compliance program is not merely a suggestion but a necessity. The OIG’s updated guidance underscores the importance of a proactive approach, encompassing seven key elements: comprehensive policies, dedicated leadership, consistent training, clear communication, complaint resolution, disclosure protocols, and stringent enforcement. Crucially, these elements should be woven into the fabric of daily operations, fostering a culture of compliance from the top down.
Beyond the Basics: Risk Assessment and Mitigation
Identifying and mitigating risks is paramount. Common risk areas include referral relationships, transactional arrangements, and interactions with telehealth companies. Medical necessity, a frequent target of audits and investigations, requires meticulous attention to billing practices, pricing, and ICD-10 code usage. Staying abreast of special fraud alerts and ensuring marketing materials align with regulatory standards are also vital.
Medical Necessity: A Deeper Dive
Medical necessity, the cornerstone of compliant billing, necessitates a thorough understanding of Medicare’s standards and payer policies. Labs must navigate the complexities of NCDs and LCDs, recognizing that the absence of formal coverage determinations does not negate the requirement for services to be reasonable and necessary. While labs typically follow physician orders regarding medical necessity, they are responsible for not billing for services they know are not appropriate.
Practical Strategies for Revenue Cycle Management
From a revenue cycle perspective, the webinar offered practical strategies for managing medical necessity, distinguishing between standard and complex medical necessity. Leveraging technology, such as APIs for real-time edits, can help identify non-covered tests and ensure compliance with payer policies. Moreover, proactive physician education and denial monitoring are essential for mitigating risks and maintaining revenue integrity.
Responding to Audits: A Proactive Approach
Audits are time-sensitive and can be very time consuming, but identifying audits promptly through AI and OCR technology, prioritizing medical record requests, and leveraging automated work queues will ensure the audit requirements are met with the deadline date.
Key Takeaways:
- Proactive Compliance: Build a strong compliance culture with written policies, training, and open communication, and review on a regular basis.
- Targeted Risk Management: Identify and address risks in referrals, billing, and marketing.
- Medical Necessity Adherence: Understand your payers and medical policies.
- Data-Driven Decisions: Use analytics to monitor denials and quickly identify claim issues.
- Efficient Audit Response: Implement self-audit systems for rapid identification and response.
To gain a comprehensive understanding of laboratory compliance and medical necessity, and to learn how to implement these best practices within your organization, watch the on-demand webinar.
Disclaimer: This overview provides general information and practical tips for consideration. It is not intended as a substitute for professional legal advice. Consult with qualified legal counsel for guidance specific to your situation.
Pathology Billing: 5 KPI’s to Identify the Health of Your Practice
Ignoring your revenue cycle? Avoid financial losses and growth limitations by focusing on these metrics.
