Is it growing as a trend?
Mike Kovacs (Quadax): It seems to be, but we’ll have to see how things level off throughout the year.
I’d like to comment on efficiency. With the downward pressures on reimbursement, we are focusing on front-end efficiencies—knowing the increasing prior authorization requirements, identifying the billing requirements, and knowing the payers—and using application programing interfaces to enhance our overall process.
There’s nothing better than a good, clean claim. It’s a big job for anyone involved in billing and collection. Wendy Baehne, do you agree?
Wendy Baehne, chief product officer, revenue cycle management, Telcor: Absolutely. With all the downward pressure, the efficiency must be up front. Prior authorizations have to be up front; you don’t want a denial and then have to try to appeal. Appeals are expensive. Clean claims are the key. If you can do that efficiently, it goes a long way.
Mark Tuthill, can you comment on the issue of prior authorizations?
J. Mark Tuthill, MD, division head, pathology informatics, Henry Ford Health: One problem we have is with the status of the prior authorization. Once we’ve submitted it, the question is, has someone approved it, denied it, or ignored it? Epic has a function that does that, and we have built a dashboard that shows the status of prior authorizations and notifies us when the status changes. If someone denies or approves it, it shows up on our dashboard. If it’s been sitting for a period, it turns yellow, meaning it’s dragging on. This is very helpful. Prior authorizations are critically important to our precision medicine program in which the testing is expensive and we won’t even do it if we don’t have authorization.
Dr. Cardona, would you like to comment?
Dr. Cardona (Wake Forest): The CAP has been looking at ways to do gold-carding or something in the advocacy space to mitigate the burden of prior authorization. One idea was to explore what kind of data we can generate collectively that could demonstrate that these providers, or this care setting, are appropriately using molecular tests, for example. Are there thoughts from billing organizations on this, and do you think a joint effort could be successful for laboratory medicine in general?
Mike Fauver, you work with medical associations and know many CAP members. Can you address that question?
Mike Fauver (XiFin): There are potential benefits from gold-card programs to mitigate the burdens of current prior authorization processes. We have collaborated with customers to help them demonstrate cases where data show they are consistently meeting medical necessity and payer policy requirements, and as a result, prior authorizations should no longer be required. XiFin also has genetic counselors on staff for molecular testing-related prior authorizations. We’ve incorporated their feedback into the prior authorization process to identify the clinical questions and information our lab customers should be collecting up front to maximize prior authorization approvals. We’ve started to incorporate this data into our AI projects as well. Gathering this data may also help our lab customers secure those gold cards.
When I’m at the American Society of Clinical Oncology annual meeting, I’m struck by how low the percentages are of patients receiving the biomarker testing they require. It would seem only dedicated academic programs have the time, personnel, and temperament to persevere in obtaining these prior authorizations. So a gold card would be highly useful. Where are we on that journey from your perspective?
Mike Fauver (XiFin): We still have a ways to go, but that doesn’t mean we can’t get there. We believe we can help our customers close the gaps, get the appropriate responses, and get the gold card in place. XiFin is looking to partner with labs and associations, as well as payers, to advance those processes and programs.