CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Dowd
So how do you keep such costs in check? “You automate,” Dowd says, echoing the sentiments of Larson and Droste. Automated solutions can ensure a seamless process for up-front prior authorizations, pre-eligibility checking, insurance validation, co-pay or deductible collection, CPT code validation, and retrieving accurate patient information, of a general nature, from referring physicians, hospitals, nursing homes, and other providers.
Among the more recent examples of billing software automation are electronic alerts for missing information and automatic requests for additional information that are sent to ordering physicians. Comprehensive billing systems can also identify when physician-supplied codes are not payable for diagnoses prior to tests being run, allowing labs an opportunity to obtain corrected codes that will avert denials.
The need for “clean information” is paramount, Droste emphasizes, but billing systems receive data from electronic medical records, physician portals, and other outside sources, and labs cannot control the accuracy of what is sent to them. In its quest for clean information, Droste continues, SCC has “developed a ‘demographic bridge’ that allows a lab’s billing system to look into the doctor’s practice management system and retrieve, for example, updates to the patient’s insurance demographics, which can be checked for eligibility coverage, and then update the demographics in the lab’s system. It is an innovation that gives labs the ability to electronically grab updated information without bothering the physician’s staff or patients.”
Data culled from modern billing systems may also help labs gain market share. Droste points to the ability to produce side-by-side comparisons of physicians with the same specialty so labs can track their test preferences and group their ordering patterns. “Now we can look at all those doctors ordering for a particular lab and see what kind of tests they are ordering. It is an interesting twist on analytical reporting,” he says. “Labs have the data that can help them market a particular test to a practice that shows preference for that genre of test.”
Larson
Payer mix can also be assessed relative to market penetration. “When a lab provider takes on a physician office, they see x amount for test volume. But now we are also able to see how much of those tests go to Blue Cross, Medicare, and Medicaid, etc. This is important,” Droste says, “because some HMOs, other insurance plans, and even self-pay patients may yield lower reimbursement when compared to other payers. So while a lab does want its fair share of that lower hanging fruit, it also needs to monitor for a good payer mix that takes into account historical payer reimbursement and associated test volume to forecast reimbursement potential and risk exposure by client.”
Allowing patients electronic access to billing information can also strengthen a lab’s profitability, Larson says. “We have had customers who have collected significantly more money by implementing a patient portal,” she explains. “It allows the patient to see what the payer paid, see what they are personally responsible for, pay by credit card, and get their statements by email.”
Advances such as these, however, require that labs and billing system vendors be attentive and flexible. “The world of billing rules changes every three to six months,” says Droste, and software vendors must constantly address these regulatory updates. At the same time, labs must be vigilant because “payers make changes to their portfolios and don’t necessarily tell labs,” adds Dowd. “If you are not on top of it and not watching your own receivables, you stand to lose a lot.”
Due diligence has its rewards. “Labs actually get a return on investment on robust billing systems in less than 12 months,” Larson says. Adds Droste: “Good business means good medicine. You must have the revenue stream to support your hospital’s mission.”
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Valerie Neff Newitt is a writer in Audubon, Pa.