Category: For Laboratories

Larger Payments for Labs Producing Faster COVID-19 Results

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CMS incentivizes labs to complete high throughput COVID-19 tests quicker

The Centers for Medicare and Medicaid Services (CMS) recently announced starting January 1, 2021, Medicare will pay $100 to laboratories that complete high throughput COVID-19 diagnostic tests within two calendar days of the specimen being collected. Also effective January 1, 2021, for laboratories that take longer than two days to complete these tests, Medicare will pay $75.

COVID-19: Insurers Exempt from Covering Workplace Testing

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Must Cover “Medically Appropriate” Tests Only

The rapid rollout in March of the federal FFCRA (Families First Coronavirus Response Act) and CARES (Coronavirus Aid, Relief and Economic Security Act) Acts – and specifically section 6001 of the FFCRA, which defines requirements for insurers – has left providers, labs and insurers uncertain, at times, of their respective responsibilities for COVID-19 testing.

Is Your Lab Collecting What It’s Owed?

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With so much of healthcare reimbursement administered by contracts, expected net patient service revenue is often a function of the payment terms and conditions found in payer-provider contracts. In order to identify underpayments, wrongful denials and shortfalls, labs need an effective, automated contract management solution as part of their A/R processes.

Why Contract Management?

Regardless of laboratory type or size, every lab can benefit from automating the validation of every single claim against the contracted amount. A proper contract management solution helps to increase a laboratory’s revenue by identifying every dollar that should have been paid per provider contracts, supplying data for contract negotiations, powering accurate revenue forecasting, and decreasing manual work hours dealing with contracts; all while automating underpayments and denials to help achieve 100% collectability.

5 Tips to Help Plug Revenue Leaks

    1. Utilize contract modeling to build all net patient service revenue contracts, provider-to-client invoice-based contracts, all payment terms and conditions, for multiple years, including:

• Medicare/Medicaid schedules
• Government, third-party payer and client billing fee schedules
• Fee schedules for non-contracted payers
• Percent of charges
• Percent of Medicare
• Carve outs
• Outliers

    1. Create and maintain an actionable workflow to help pursue priority claims during pre-billing based on expected revenue versus total charge. Be sure to define payment variance rules and apply post adjudication to determine next steps.
    2. Validate charges to prevent charge master errors before a claim is submitted by configuring non-contracted payer rules to validate acceptance of patient co-insurance.
    3. Take advantage of cash flow analytics and variance reporting to calculate cash flow by payer, age of claim, and where the claim is in the revenue cycle. This analysis and reporting will help identify opportunities for maximum cash flow improvements in the revenue cycle. Variance reporting specifically will provide an immediate indicator of adjudication outside contracted rates.
    4. Simplify the collection and revenue recovery process by identifying underpayments to trigger automated appeal process.

Plug your revenue leaks by identifying and collecting on underpayments and wrongful denials by being armed with the correct contractual data to appeal and overturn them. Contact us today to learn how Quadax can help you collect what your lab is owed!

Surprise Billing Legislation: Ways to Mitigate Your Risk

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Nearly 60% of insured adults have received a surprise bill on a healthcare service they thought was covered by insurance. And whether care or the provider is in-network, out-of-network or a mix of the two, 1 in 5 of these insured adults find it difficult to pay their deductibles.2 Why is this happening and what is being done about it?

Due in part to narrow provider networks, surprise bills can be the financial result of a patient receiving in-network care by an out-of-network provider, often the bill being the difference between the charged and the allowed amount of a service. These surprise bills can cause undue stress and have detrimental financial effects on the entire household, such as delayed payment on other household expenses, mounting credit card debt, and more. As such, state and federal legislations are responding in kind with laws around surprise bills.

 

STATE LEGISLATION

A number of states have enacted comprehensive laws to protect some patients from surprise medical bills, including California, Oregon, Illinois, Florida, New York, New Hampshire, New Jersey, Connecticut and Maryland. Additional states, including Texas, Colorado, New Mexico, and Washington, have passed laws expected to take effect this year. In essence, these laws are meant to protect consumers from surprise bills by limiting providers to the applicable in-network cost, setting a state payment standard, and/or establishing a dispute resolution process.3 Meanwhile, more than a dozen more states have enacted a limited approach to mitigate surprise bills.

 

FEDERAL LEGISLATION

Federal action is necessary to address certain aspects of surprise bills for people enrolled in self-funded plans due to the Employee Retirement Income Security Act of 1974, or ERISA.  Legislation is expected to be passed in fall of 2019.

Both state and federal initiatives can be summed up as:

  • All proposed legislation includes a ban on balance billing patients
  • Most legislation is specific to emergency and ancillary providers at this time
  • Many of the proposed state and federal bills include stipulations for using usual and customary rates as a basis for negotiation
  • Arbitration clauses included in many of the proposed bills is considered favorable to providers
  • Indexing against usual and customary rates seems to be included in more of the state initiatives

What can you do?

To help avoid and mitigate the risk of surprise bills, more and more hospitals and clinical laboratories are rethinking the patient experience and investing in tools to help provide pricing transparency on procedures and services, like testing. These tools utilize basic patient demographics (name, birthdate, address, insurance provider, etc.) to validate insurance coverage and eligibility, perform advanced benefit investigation to uncover plan-specific coverage details, assess prior authorization rules, and most importantly provide a patient’s expected out-of-pocket cost. Taking it even further, labs can identify a patient’s propensity and willingness to pay to help assess the need to offer financial assistance. This entire approach, called Patient Access Management, can help clinical labs and providers alike offer the transparency needed to empower a patient to make financial decisions regarding their care – perhaps the patient cannot afford the test so an alternative treatment plan has to be put into place. Patient Access helps to improve the patient experience in that the patient understands exactly what they will owe for the test – and no surprise bills. For a growing molecular lab, this can mean the difference between writing off bad debt and securing expected revenue.

To learn more about Patient Access Management solutions offered by Quadax and how they can help mitigate the risks of surprise bills and more, contact us today!

 

  1. http://www.norc.org/NewsEventsPublications/PressReleases/Pages/new-survey-reveals-57-percent-of-americans-have-been-surprised-by-a-medical-bill.aspx
  2. https://www.consolidatedcredit.org/infographics/medical-debt/#gref
  3. https://www.healthsystemtracker.org/brief/an-examination-of-surprise-medical-bills-and-proposals-to-protect-consumers-from-them/#