Billing practices, problems — we ask the experts

I’m assuming there are well-executed combinations and some that are less well executed. Al, are most people worried about this billing on the back end after they’ve already hashed out the merger of the practices?

Al Sirmon (Pathology Practice Advisors): In my experience, billing is not one of the big issues considered up front. Usually they’re trying to merge for other reasons. Many times it’s because the hospital is pushing them to do so. As the hospital systems merge, they expect their underlying practices to merge. That’s what I’ve seen the most.

Billing should be front and center if they’re contemplating a new arrangement of practices. Matt, don’t you agree?

Matt Zaborski (APS Medical Billing): Yes, you’re buying someone out of their practice or giving them value of the overall based off of numbers. I don’t know why you would not include the billing performance as part of that, and it’s at the core of what it is outside of, say, your part A stipend. A poorly performing billing arrangement for the group being absorbed can lead to a drastic undervaluation.

What’s the status of professional component billing in pathology? Tom, where do you see that in 2020?

Tom Scheanwald (APS Medical Billing): It’s still a viable revenue source for many practices that take advantage of it, and many are interested in doing so. Where it’s going to be in 10 or 20 years is up to us. We have to embrace it as a revenue source and we have to begin working with payers who don’t recognize or pay for that service. So often people are okay with walking away from it as a revenue source, and as things get tighter, we’re going to have to make sure our clients are billing for everything they can.

Matt Zaborski (APS Medical Billing): The surprise bill laws are making a dramatic impact, but that’s state by state, so it’ll be interesting to see how the federal government handles it versus each state, because a lot of the states’ language will say “on Medicare-covered services.” A professional component of clinical pathology doesn’t fall under a Medicare-covered service, so it creates its own gray area. Going back to what Tom said earlier on being active in state and national organizations, engagement with these organizations is imperative to help protect revenues from payer and legislative actions.

Kyle Fetter, three years ago we talked about the need to be able to withstand increasing scrutiny of billing, to make sure bills are clean, to optimize the money that will come into practices, and the importance of analytics. Are those still things you worry about on behalf of clients?

Kyle Fetter, executive vice president and general manager of diagnostic services, Xifin: Yes, absolutely. We have a combination of products here in terms of technology and services, so to us there’s been a patient engagement theme going on for some time wherein it was necessary to be able to provide patients certain information commercially up front regardless of regulatory requirements. From a business standpoint, billing has been problematic for a while in that patients get bills they typically don’t understand, they didn’t know were coming, or that maybe were not fully disclosed to them, and it manifests itself in a lot of ways. So there’s been a business need for patient engagement for a long time, and technology tools that support that have been critical, things that tell patients what they can expect to have to pay. This is particularly so in pathology, where there is more reflex testing and things like that, so it’s not simply about an ordered test. And then there’s the issue that we run into of tightening up commercial guidelines on what will be paid and when, which for a lot of our customers has resulted in an increased need for appeals.

I’d like to hear more about how a pathology practice optimizes its patient engagement so the patient is not left surprised or angry and calling their local representatives. What are some of the things you’ve seen that have been working on behalf of the client?

Kyle Fetter (Xifin): It depends on the nature of the workflow for the pathology group. For us, patient engagement becomes a tool around being able to take the information that comes in from a payer during an eligibility check, marry that up with the potential services ordered, and in that eligibility check you have key benefits information. You take that benefits information and marry it up with the potential outcome of that order in terms of contract rates by procedure, and provide a disclosed estimated responsibility based on that order with the correct language around it that says other things may be ordered. From an electronic standpoint, if you can get that information to the ordering physician and the patient as early in the process as possible, it’s great. A lot of these orders move around on paper, though, and that inherently has some issues.

We’ve noticed with some of our much more expensive service practices, they may be reaching out to the patient up front and sending an email notification to that patient that then gives the patient the ability to authenticate from a HIPAA standpoint. Then it’s a notification that a service is about to be performed and to understand your estimated benefits, please click this link, and then you have to authenticate for security reasons.

You’ve offered us an important approach to preapprovals and clean claims and so on. Al, can you comment on how to manage the patient a little better in a pathology practice?

Al Sirmon (Pathology Practice Advisors): We engage the patient in three ways. The most important one and the one we’ve dealt with the most is having a good call center. When that patient gets a statement and has a question about it, there has to be a call center where they can get their question answered promptly.

The second is the patient statement, which is the first way we contact the patient. We tell our clients it’s a good idea to sit down and look at their statements and if they can understand them, then maybe the patient can understand them. Many times we hear complaints about the EOBs the insurance companies send out. Many people can’t understand them because of the way they’re worded. It’s the same with our patient statements.

The third is the patient portals where patients can see their accounts and even make payments or a payment plan. We didn’t see much of that in pathology in the past. We’re starting to see it now.

Kwami, would you like to comment on that, not only from a pathology point of view but also from a clinical laboratory billing point of view?

Kwami Edwards (Telcor): You do have to have a good apparatus that is structured around the patient. The communication to let the patient know in advance who you are as a laboratory or as an organization and that they may receive a bill is important. It helps the patient to better prioritize that bill when they receive it. It’s also important to understand and leverage tools, the various systems out there, to make sure claims are routed to the right jurisdiction, that they are going to the right place with the least amount of involvement from the practice. And it is about a multipronged approach. Being able to deliver statements with various options to pay, recognizing and identifying patients who may qualify as charity or indigent populations, and having a good process around adjustments for that and having portals as well. The best thing we can do is provide a straightforward and streamlined way for patients to understand what’s happening. And when they do have questions, make it easy for them to get the information they need.

Bob Dowd (NovoPath): We’ve worked with some of our multiple entity clients to distribute information to their patients up front that says, “Yes, you’re going to be receiving a statement from us but you may also receive a statement from the ABC Pathology Group, which is our partner, and this entity may do this component of your test.” So there is no surprise.

Kyle, we’re hearing a lot about the burden of preapprovals for testing and the panels that are getting ever narrower and more difficult to enter into. What are you seeing at Xifin with regard to both of these?

Kyle Fetter (Xifin): The issue related to the rollout of laboratory benefit management programs where payers have made an investment in these groups to potentially put utilization controls in front of a lot of testing, from a medical standpoint, has always been that this is critical testing, required within a timely manner in many cases. Delays around things like prior authorizations have been a big problem for laboratories and pathology groups for a long time because at the time an order is received there’s a timeliness to it, and generally the one who’s ordering it isn’t going to do the prior authorization for you. This is a problem that only technology and a business focus from pathology groups and diagnostic companies in general can resolve, and it’s two parts.

One, there’s an inherent benefit to the pathology group or lab of parts of the prior authorization process, which is that you receive certain medical and clinical information about the patient that if you were receiving an order alone you would not get. So it’s okay from a procedural standpoint and technologically to take additional pieces of information from the ordering physician that are ultimately going to be required, things that would typically come off a medical record, to get a prior authorization. It’s a nice reason for pathologists and other diagnostic providers to get information clinically on the front end. To make it not a burden for ordering physicians, though, it has to be easy to do.

If there’s a requirement that UnitedHealthcare, for example, is driving, make sure you’re providing them electronically with a way to fill out quickly the UnitedHealthcare prior authorization form. You need to know up front, then, if this service for this payer requires a prior authorization, and only in that case are you going to put that burden on the ordering physician to do it. That requires technology.

Taking that a step further, you have to then be able to provide that information succinctly to a payer, and what unfortunately happens is even when you put prior authorization numbers in the correct locations on the claims, often you run into issues with the payer where they’ll kick it back and say they didn’t get the prior authorization number for various reasons, and so you have to be able to handle that from a technology standpoint.

The last piece is that a lot of providers over time have had a prior authorization requirement put in place and then lobbied and/or worked and appealed with the payer to get them to remove the requirement because it is a burden to the ordering process. It slows testing for patients and often it’s critical and time-sensitive testing. Providers have had success in getting payers to remove those requirements for time-sensitive testing.

Would anyone else like to comment on preapprovals and preauthorizations? Al, do you see a rising tide of this among the people you consult for?

Al Sirmon (Pathology Practice Advisors): Some but not yet as much as you might think, but I deal strictly with anatomic pathology.

Matt Zaborski (APS Medical Billing): The prior authorization conundrum does tend to lie more on the clinical laboratory side than the anatomic side. Some medical groups capitate certain populations’ testing to Quest or LabCorp if they’re outpatients, not inpatients. Seema Verma [administrator for the Centers for Medicare and Medicaid Services] indicated on February 11 that this year Medicare as a whole is going to be taking a look at prior authorization, so I would expect some changes to it, at least at the Medicare level, and then you tend to have other payers follow suit.

And there’s hope in that? Or is it going to be a great problem?

Matt Zaborski (APS Medical Billing): The claimed goal is to reduce waste and provide administrative simplification. I would expect the process to utilize more online tools and be technology ready.

Any final comments from the group?

Bob Dowd (NovoPath): Your readers should know we’re doing everything we can as far as the billing process and the front end where you’re doing pre-eligibility, verifying demographics, and so on. We’re also doing everything we can software-wise to build in regulations, coding nuances, proper coding, highlighting errors, things like that so when that bill is ready to go out, it has received all the scrutiny needed to minimize reimbursement problems.

We’ve also done a lot to do automatic appeals where you have the ability to edit your appeal letter, and since everything’s digitized, you can combine reports, slides, anything you’d like to do with that appeal. So we’re making it easier for people to have efficient billing.

Matt Zaborski (APS Medical Billing): Whether groups are going to bill internally or externally in an outsource model or move from one outsource model to the other, they should focus on picking a partner with whom they can see growth in the relationship, clear communication, and honesty. Those are the people who are going to go over the issues on a regular basis and put that effort into the relationship.

Kwami Edwards (Telcor): I agree with everything that’s been said. Every organization has to find a partner that makes sense for them, can evolve with them, and can develop a great tool and also guide them with a process so they can continue to be more profitable. Collecting more is great, but you don’t want to spend more on staff and infrastructure to get there. It means having assistance and guidance from a partner who is going to evolve their thinking and technology—one who will listen and help you get there—and a lot of groups are trying to do that.

Simply switching out the tool you’re using isn’t the solution. You need to have something that is going to serve you not just for the next year but for the next five or 10 years and be scalable.

Al Sirmon (Pathology Practice Advisors): We’ve all talked about how billing is getting tougher, but on the bright side we have better tools now—you can almost use the term data mining. Even for a small pathology practice, there’s a wealth of information located in their billing system, and now we have the ability to go in there and drill down and extract that, put it out on Excel or a pivot table and you can learn a lot about your practice. We’ve just got to convince our groups they need to take the time to do that, and with the average group being so small, they need someone to support them in doing it.

Kyle Fetter (Xifin): For many of us that do development in services in this space, we’re trying to figure out how to help our customers—pathology groups or other types of diagnostic providers—provide a good experience for their ordering physicians and patients. It’s a combination of many things.

If prior authorization requirements are kicking up, whether it’s immunohistochemistry or more cytopathology work or things like that, then use it as a touchpoint for your ordering physicians. Whether it’s through technology or through time to speak to them, people should leverage these requirements to get closer to their patients and their physicians. That’s at the core of any development we’re doing from a software or service perspective.