Dr. Cardona, can you weigh in on this same question?
Dr. Cardona (Wake Forest): As you get larger, it is logistically more complex trying to standardize and rein people in. However, the size protects you from being carved out of plans. If you’re too big and covering a large population of lives, insurance companies can’t ignore you. It also helps protect from contracts that steer lab business away from local hospitals to the larger referral businesses. Legislation is being introduced in Virginia to help mitigate the steering of lab business away from the local community, because it leads to fragmented care.
Do you share Mark’s enthusiasm for having IT involvement in billing and collection?
Dr. Cardona (Wake Forest): I’m jealous he has that with his team. We have Epic, and we have a great IT team but they are pulled in a million directions. Getting labs to be on top of the priority list can be a challenge. If you have control over a lab-specific IT team, you can be much more successful. If you incorporate billing and revenue cycle into that, even more powerful.
Wendy Baehne, give us your thoughts on what we’ve been discussing.
Wendy Baehne (Telcor): In large hospital systems, the laboratories tend to get buried because overall they’re worth less to the hospital system than other departments, so many of the rules for billing out the lab fall to the wayside. Having separate systems and teams for the lab can be beneficial.
We not only do billing for outreach laboratories, we also do what we call a pass-through model, where we ingest the charges, scrub them, go through the rules, figure out the billing, and send it to the hospital to bill it out. It helps to have a separate level of expertise and efficiency to get the bills out and paid the first time.
Mike Fauver, what is XiFin’s philosophy on the matters we’re talking about?
Mike Fauver (XiFin): I agree with Wendy’s point. In a large health system, enterprise staff often try to focus on all types of claims, but it’s challenging for them to keep up with complex lab-specific policies and understand prior authorization and coverage policies. And with lower-dollar claims that have any issues, they often hit hospital write-off thresholds.
We have the staff, technology, and expertise to focus on laboratory claims, especially in hospital outreach and ambulatory services, and it becomes critical to partner with one of the companies on this call to get high-volume, lower-dollar claims effectively and efficiently reimbursed.
Mike Kovacs, does the trend toward subspecialty pathology, particularly in large institutions, contribute to better billing and collection or does it not make a difference?
Mike Kovacs (Quadax): It makes a difference because typically subspecialties can have different workstreams and need to be handled differently. Also, labs need financial reporting to track payment and denial trends per subspecialty. We track subspecialties independently and provide trend analysis and detailed financial data to our clients.
Dr. Cardona, your comment on subspecialty pathology as it relates to billing? Could it improve billing?
Dr. Cardona (Wake Forest): In theory it should because they’re following best practices guidelines and should be up to date on best practices. Now that documentation for a procedure or test is becoming more and more important, their documentation might be better at explaining why something has been ordered. From that perspective, it could improve billing.
Dr. Tuthill, your thoughts on this?
Dr. Tuthill (Henry Ford): I agree with Dr. Cardona. Interestingly, subspecialty billers typically train pathologists on billing because of the many subtleties and nuances. They improve the revenue capture. They’ve had more denials so they have more experience with the documentation, and they help us with our designs. We do a lot of templating; we build out quick texts that can be dropped into reports, which makes it easy to explain what you did and why.