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Billing headwinds grow stronger for labs
April 2024—In billing for pathology and laboratory services, the hurdles are only getting higher. Narrow networks, prior authorizations, claims denials. Payers “have deeper pockets and figure they can outlast us,” said Joe Saad, MD, chair of the CAP Council on Government and Professional Affairs, in a Feb. 14 roundtable led online by CAP TODAY publisher Bob McGonnagle.
He and others talked about AI, digital pathology codes and molecular Z-Codes, biomarker testing, and unity within the laboratory community.
During last year’s roundtable on billing systems we talked about three principal items that were top of mind: the No Surprises Act, the increase in demand for prior authorizations, and denial of payments. Joe Saad, are those still the most important items you think about when you think about pathology and laboratory billing?
Joe Saad, MD, chairman of pathology, director of anatomic pathology, president of medical staff, and medical director of laboratory, Methodist Health System and Methodist Dallas Medical Center: Yes. They’re interrelated because the No Surprises Act has emboldened many payers to pull certain tricks on us, like narrowing the networks, denying claims, and making us jump through hoops with laboratory benefit managers, prior authorization, et cetera. Payers are in the driver’s seat. They can challenge us, and if we don’t like it they don’t mind if we go out of network, which gives them the upper hand when it comes to payment. They know it’s time-consuming, laborious, and costly if we want to contest it, go through the negotiation period, and go to arbitration. They have deeper pockets and figure they can outlast us.
It’s important to press network adequacy laws in various states to limit their ability to sidestep us with inadequate networks, invoke the No Surprises Act, and challenge us to go out of network.
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