Summary
Pathology Associates of San Antonio and Pathology Reference Laboratory (PRL) implemented Telcor’s revenue cycle management software to improve billing and collections. The No Surprises Act requires facilities to provide good-faith estimates of potential out-of-pocket costs, which PRL calculates based on average billed charges for specific procedures. This approach helps ensure clean claims and improves the likelihood of timely payment.
Sponsored Roundtable
November 2025—This is the third of a new feature in CAP TODAY: a one-on-one virtual roundtable in which CAP TODAY publisher Bob McGonnagle speaks with one vendor and one or more laboratory experts to spotlight a company and a customer for their laboratory solutions and work.
Sarah Stewart of Telcor, which sells laboratory revenue cycle management software and services, and Jeanette Gray and Scott Rupnow of Pathology Associates of San Antonio and Pathology Reference Laboratory, spoke with McGonnagle on Oct. 1.
Jeanette Gray, tell us about your laboratory.
Jeanette Gray, vice president of revenue and payer relations, Pathology Associates of San Antonio and Pathology Reference Laboratory: We are a physician-owned practice in San Antonio and we operate a laboratory that does primarily anatomic pathology and women’s health testing. We have about 20-plus pathologists on staff. I joined the practice in July.
As you walked into this new position, what did you see at Pathology Reference Laboratory [PRL] that made you think help from Telcor could be of use?
Jeanette Gray (PRL): Prior to my arrival here, PRL implemented Telcor from a fairly antiquated homegrown billing system. PRL brought Telcor on board to improve billing and collections and automate many of the manual processes. I’m analyzing what they’ve implemented and trying to further improve the processes.
Scott Rupnow, you’ve been with PRL for two years as its CEO. Prior to that, you were with ProPath for 17 years. When you arrived at PRL, seeing a homebrew system that didn’t have all the billing bells and whistles probably made you think of reaching for a better solution. Is that right?
Scott Rupnow, CEO, Pathology Associates of San Antonio and Pathology Reference Laboratory: Yes, and collections and billing get more complicated every year. We needed transparency and automation; we didn’t have either with our legacy system.
Sarah Stewart, I would assume you’re used to having new customers like PRL reach out to Telcor when they realize they need a more sophisticated approach to billing, collections, and revenue management.
Sarah Stewart, vice president of revenue cycle services, Telcor: That’s correct. Whether it is a customer like PRL that does the billing with its own staff or a customer that comes to my billing service team, it is looking for a solution that can handle the complexities of laboratory and pathology billing, such as splitting the TC/PC and the global charges by payer and following payer rules for national and local coverage determinations. A lot goes into laboratory billing, so you need a flexible system that allows you to configure those rules and update them easily as payers make changes, because they make changes daily and they’re not always well publicized in advance. A flexible system allows my team or a lab like PRL to pivot and put rules in place to get clean claims out the door the first time.
Many people in the field of anatomic pathology have said the cardinal sin in billing and collections for pathology practices is to rely on the hospital billing system. Tell us why that’s true, Scott.
Scott Rupnow (PRL): The hospital billing system is an entirely different animal than the lab billing system. And since pathology revenue is a small portion of the entire hospital revenue, you won’t get the attention you need to maximize revenue.
Jeanette, when you send out bills, they have to be clean and clear for the recipient of that bill, correct?
Jeanette Gray (PRL): Yes. Most patients do not understand why they’re getting a separate bill from hospital-based physicians, including pathology. From an independent lab standpoint, patients may not understand that their specimen even came to our laboratory and why they’re getting a separate bill from a lab when they already paid the copay. It’s important to be clear and explain it well not only on your billing statements but also when staff take patient inquiries on the phone.
Sarah, how did the No Surprises Act affect your life at Telcor?
Sarah Stewart (Telcor): With our customers we put processes in place to make sure that as we’re doing pathology work, especially since the original order often comes from the hospital, we aren’t balance billing patients for unexpected exorbitant amounts. Whether that’s calculating and providing good-faith estimates up front and using them in the system to control what goes out in the patient statement, there’s functionality in the system and more attention is put on those patient bills. If it’s an out-of-network patient seen at an in-network hospital, we make sure we’re keeping those bills reasonable, even when the payer denies and says the full bill is the patient’s responsibility.
Jeanette, tell us how the No Surprises Act works on the ground for a patient who goes into a hospital and may get a bill from an entity or person they’ve never heard of.
Jeanette Gray (PRL): When a patient goes to the hospital, is admitted, and signs the paperwork, most often electronically, the paperwork includes hospital charges, but it also clearly states that it does not include physicians who may see the patient, such as the treating physician or a specialist, or ancillary testing not based within that hospital. That’s all separate.
The hospital is required to know all the potential costs involved in a patient’s service. So if the patient says they would like a good-faith estimate of their potential out-of-pocket costs up front, it is that facility’s responsibility to provide it as the conveying provider. However, it is also our responsibility as a pathology practice and/or laboratory to help the hospital or facility have the information they need to provide it accurately to the patient.
Getting pathologists paid for the services they provide is a big responsibility, but you’re also doing a lot of work for the facility where a patient might be. Is that right?
Jeanette Gray (PRL): Yes. With anatomic pathology versus clinical pathology testing, how you estimate the out of pocket will be different. In pathology most patients will have a biopsy, but if they’re having a colonoscopy, for example, you won’t know how many biopsies will come from it. Once it gets to pathology and a pathologist looks at the specimen under the microscope, we don’t know how many special or immunohistochemistry stains might be ordered or if there will be additional testing. It is unpredictable.
The best practice I have found is to look at your average costs—billed charges, not reimbursement—because under the No Surprises Act, you have to be within $400. Look at your billed charge and figure out what your average charges are, if you can, for the type of surgery. For adenoids, tonsils, gallbladder—what is it? If you can get down to that level, you can provide fairly good estimates to patients on the billed charges. If they have insurance, or you provide discounts for self-pay, or if you’re out of network, you shouldn’t be above your billed charge.
Sarah, by virtue of this estimate, which I assume you help make on behalf of your clients through your software and service, you’re improving your chances of collection without dispute, correct?
Sarah Stewart (Telcor): Yes. You want it to be a good-faith estimate. You don’t want the bill to be higher than your estimate. If it can come in lower, great. It gives the patient information up front so they know what they’re getting into and are not surprised on the back end, when they get a bill, that their insurance may not cover it because the pathologist is out of network.
The in-network group or physician has accepted a predetermined level of pay that is often lower than what the out-of-network physician or group would accept. Is that a reasonable general rule of thumb?
Sarah Stewart (Telcor): In network means you have a relationship with the payer and a contract with the payer. You have agreed to certain rates with the payer, and the payer has agreed to process your claims more easily. When out of network, you can get denials right off the bat. Then you have to appeal to try to get it covered. With in network, you should be able to better predict your reimbursement from that payer and have fewer appeals. The rates may or may not be lower than out of network, but it’s less effort to get paid and there’s less patient responsibility for payment. Many patients have no out-of-network coverage or have higher out-of-network deductibles and costs.
Jeanette, do you agree with that explanation?
Jeanette Gray (PRL): Yes. Many times if the hospital is in network, the payer will process hospital-based pathology, radiology, anesthesiology, and emergency department care as in network because the patient technically had no choice. Those claims can often be appealed if the facility is in network. At PRL we work with the hospital to make sure we are in network with as many plans as we can so those situations don’t arise for patients.
Does that usually involve a negotiation around charges?
Jeanette Gray (PRL): Yes. There are some situations, usually with hospital-based providers, in which payers may not want to contract with you, or the rates are so low they’re below your cost and you may not be able to contract with them. With the No Surprises Act and other legislation, there is a payer responsibility to process that and be transparent with its reimbursement rates so you are treated as if you are in network if you’re out of network. But that definition is so broad and general that it doesn’t give guidance to payers or providers to know exactly what it means.
This adds an extra layer of complexity to the pathology service, whether you’re in network or out—you do a lot of work to get in network, and if you’re out of network in another place or plan, you have to be careful that you’re going to get adequate compensation. Is that right?
Jeanette Gray (PRL): Absolutely. And pathology, in general, is the smallest spend for a hospital and for a payer. Sometimes you have to educate the payers to understand that the results of pathology and lab testing dictate almost 80 to 90 percent of the treatment, either within the hospital or the physician’s practice. It’s important that testing is done if it’s medically necessary. More and more policies are trying to put speed bumps in the way of getting paid.
We hear from pathologists and their groups that it’s much more difficult to get paid and get a claim that’s considered clean and workable on the part of the payer and plan. That’s been the trend for the past few years. Is that right, Sarah?
Sarah Stewart (Telcor): Yes. It’s harder to get in network with certain payers, and it’s harder to get paid when you’re out of network. Even when you’re in network, they add new and different rules that limit medical necessity and the number and type of tests you can do, so it is harder to get a claim paid and processed, especially the first time, without additional steps of appeals or medical records or resubmissions. It increases the administrative burden of understanding the payer’s rules and having staff who have the time and energy to fight, to be able to get paid for the work that is important for the diagnosis and treatment of patients.
How does Telcor manage the feat of making cleaner, clearer claims? You must be dealing with many different plans within the Telcor service.
Sarah Stewart (Telcor): Our base list of payers is several thousand long. Not every customer deals with all those payers, but there are many, especially with each state having Medicaid and Medicaid managed care plans, Medicare and Medicare Advantage plans, and each having slightly different rules. We have groups that specialize in different payers, whether it’s understanding Blue Cross and jurisdiction or Medicaid and the different plans in all the states, and we leverage that knowledge to all our customers.
If a customer starts to see a problem, we can collaborate and figure out what we need to do and how to attack it. The system has many configurable rules—not just NCDs and LCDs—with different parameters that can be created to address whatever new thing a payer comes up with. We don’t have to wait for the software or for our development team to catch up with the payer rules. The system can create it and say this is what we need to do for this client, this payer, this procedure, these diagnosis codes.
Jeanette, what does your staff have to know?
Jeanette Gray (PRL): Whether you have in-house billing or outsource it to a service like Telcor’s, your staff has to understand what you do and why, whether it’s sending a copy of the pathology report or getting the clinical notes from the referring physician so you can support why the test was done. You have to know how to work through the system.
To an outside eye, this looks a little like an arms race. Payers are doing everything possible to make it difficult for you to collect, and pathologists and their labs are doing everything possible to collect and to collect the appropriate amounts. Is that a fair characterization, Sarah?
Sarah Stewart (Telcor): It is a relatively fair characterization. If the payers come in with a new policy, we try to figure out what we need to do to meet that policy. When you start meeting that policy, they put in place a different rule or different requirement. By the time you figure one thing out and get the process solidified, something else happens and you have to tackle the next.
We hear complaints from pathologists in groups about networks getting narrower.
Jeanette Gray (PRL): Plans are getting narrower. Payers like Blue Cross and Blue Shield might have different networks for their HMO versus PPO, depending on the state and the products. Many times the payers/plans have one national product with a large, national clinical lab and don’t understand that clinical pathology is one thing and anatomic pathology is another. It is important they understand the difference and that the contract may require an in-state provider. That’s not necessarily true for anatomic pathology. Most national clinical labs that provide pathology have a regional or national pathology processing laboratory; they’re not located in every state. That is hard to explain when trying to get in network when the payer will contract only with a national clinical lab or requires a brick and mortar in the specific state. It’s hard for the smaller, physician-owned labs that are still operating.
If you don’t get in network with their products in the beginning, it’s hard to go back to try to get in network with a new product because if you’ve had that kind of contract a long time, they will want to reduce your rates. No one will be willing to increase your rates. I wish that wasn’t the case because rates are going down every year and it’s getting harder to have the margin you need to provide quality services to your patients.
We know we’re in a generally inflationary environment. Pathologists want to be fairly compensated and the equipment they need gets more expensive all the time, yet the plans don’t want to cover those inflationary costs. That would lead you to fall increasingly behind the curve, Sarah, which is one of the arguments the CAP and other organized groups have been making.
Sarah Stewart (Telcor): Yes, I agree. Reimbursements are going down, but costs are going up and pathologists, labs, and organizations get stuck in the middle trying to figure out how to continue to provide quality care and good outcomes with ever decreasing margins. That’s where you see labs consolidating and people coming to us, because as a billing service, we’re a bigger entity and can provide them with more knowledge than they may be able to find on their own.
Jeanette, against this background it’s all the more reason to optimize the collection as best you can, correct? That’s become the name of the game.
Jeanette Gray (PRL): Absolutely. If you can work with a group such as Telcor and on a system such as theirs that can automate and streamline more processes, have rules in place to get as much corrected up front to get a clean claim out as quickly as possible, that’s the key. But your referring physicians and hospitals also must understand they have to submit the correct information to us up front. That’s a puzzle sometimes in and of itself.
As if all of this were not difficult enough, increasingly pathology cases are more detailed. There are more parts to the examination and often additional testing needs to be done on a specimen or biopsy. Sarah, how do these additional procedures get added effectively to a bill and a claim so there is a capture of the additional tests and work that’s done? There could be a delay in that report compared with the original.
Sarah Stewart (Telcor): We’re looking for that information from our customers, pathologists, and/or the coding team that’s reviewing and adding the diagnosis codes based on the pathology report. We can automate some delay into the system. If we know it’s going to take a number of extra days on average, we can build that in to try to process it all at the same time. We’re balancing that against a payer’s timely filing and cycles so we can get things out the door in a timely fashion. You have to have good, clear communication between the systems you’re using, good connections at the hospital and with the laboratory and pathology systems that are sending you information, and with the pathologists or coders who are inputting the information clearly and quickly.
Jeanette, there are many stories of endless delays in having procedures done, extra tests, final reports, so the idea of waiting to bill everything when it’s wrapped up is not necessarily always the best strategy. Would you agree?
Jeanette Gray (PRL): Yes. If a pathologist is waiting on the results of testing that had to be sent to a reference lab because it’s a service the lab does not perform, you know that when you’re reading the report, so you know to expect it. We hold those cases because we know we’re going to get it back. You may not know if the ordering physician will want to add on another test or there’s a discussion about second opinions, for example. In those cases an addendum report will come later, and you’re not holding billing for that.
Once the case is finalized, you need good connections with your LIS and interfaces with your hospital and clients to make sure you get the orders up front, and with your hospitals and LIS to get all the charges on a case once it’s interpreted by the pathologist. The coding is typically done after the case is completed and signed out. There are times when you’re waiting on results and they’re holding a test. We might not know that in billing until the full case gets signed out, so it’s important to have those connections so you understand what’s coming in the report.
Sarah, the people doing the billing have to understand the case to know all the pieces are there that need to be submitted just to be paid, correct?
Sarah Stewart (Telcor): Yes. It goes back to the topic of why you don’t want to hand it off to a hospital or other non-lab, non-pathology-specific group, because they’re not going to understand the nuances to know what’s coming, what’s done, what’s not, and how to handle it.
How do you counsel people to speak to pathologists in the group who need tutoring about how to work up a case for proper billing? Are there tidbits you’d like to share, Jeanette?
Jeanette Gray (PRL): I am working now with the managing partner of our practice about coding—reminders of coding guidelines and other things that could be documented better. Our managing partner has been helpful in communicating with the pathologists. He and I are working together to make sure I’m giving him the correct information based on all the different reports so he can better educate pathologists on what we need to support billing.
Sarah, do you engage in similar exercises with the groups you service?
Sarah Stewart (Telcor): On our billing team we can have a billing coder who understands the billing policies and can update diagnosis codes based on what the pathologist has documented, rather than push it back and ask for a different diagnosis code. If we do have to push it back, we include information so they know the kind of policy we’re dealing with or if there’s something they can document or do differently. In some cases, although it was the right choice for patient care, it may mean not getting reimbursed. You don’t want a doctor making decisions based on reimbursement policy necessarily, but you also have to get reimbursed for the work you do in order to keep doing it. We handle the payer pieces and unique nuances so the doctors can be doctors and we’re not distracting them or putting them in a position of having to make decisions based on payer policy.
What information do you recommend a pathologist or pathology administrator have in front of them, in black and white, that you’ll want at Telcor so you can begin a process of potentially helping them?
Sarah Stewart (Telcor): They should know which payers they work with the most and where they are in and out of network. That will help us understand where the pain points are going to be and how we can get rules and other aids in place to help.
Jeanette, do you have a pet peeve in this process of sending bills and collecting?
Jeanette Gray (PRL): One is that it seems like everything is on the providers and rarely is anything required of the payers. It used to be Medicare was the reimbursement floor and now it’s the ceiling. That’s not how it should be. Payers are negotiating 50 percent of Medicare or even Medicaid, especially in states that have most-favored nation clauses in the state Medicaid programs. Providers’ hands are tied when that’s all the payers are offering. It’s take it or leave it. Unfortunately, the big labs are going to take it so they can be in network, and the smaller labs or pathology practices can’t always compete with that.
Would you like to make a final comment?
Jeanette Gray (PRL): Your leaders within the laboratory, especially in the revenue cycle management and billing departments, need to be involved and educated and participate in the discussions, attend conferences, et cetera, so they’re aware of what’s going on. You have to stay up to date on the policies. For example, UnitedHealthcare just put one down that it is going to start issuing preclaim audits for certain tests. That means they will pend the processing of claims until you give them a copy of the report. You have to prepare for that now.
Scott, a final comment?
Scott Rupnow (PRL): When we compete for a referring physician’s business, the first question the physician asks is if we are in network with all the payers. That puts us in a bind if we’re presented a fee schedule that is ridiculously low. We’re almost forced to consider accepting that fee schedule just so we don’t negatively impact the patients of the referring physicians.