2018 has seen its fair share of changes for Laboratory Billing. However, Toxicology is not one of those areas.
In our experience, many labs stumble through the billing cycle, and toxicology is the perfect example of Murphy’s Laboratory Law:
Murphy’s (Laboratory) Law – Anything that can be denied…will be denied.
As per our prediction in 2017, Toxicology has continued its convoluted processing trend.
Below, we will cover how to navigate the current payer trends to help you strategize how to maximize your revenue in 2018.
But what about 2018? What do the major areas of Distribution and Payer Requirements look like this year?
Distribution (and a lack thereof)
First of all, the varying standards by which payers pay for lab distribution levels are nearly impossible to navigate.
Per the explicit Medicare (MCR) guidelines, most confirmations should never hit level 2, but the issue here is that most labs struggle to fulfill this requirement.
However, the large majority of labs have a high distribution of their confirmations at levels 3 and 4, which only aids to increased scrutiny from the CMS.
This leads to increased chances of being audited, or worse, OIG investigations.
Second, you then have to examine your billing practices to ensure certain CMS requirements are met with testing.
For instance, there should be a certain percentage of screens that have no confirmation billed for them, even if the lab runs the confirmation automatically with the screens.
This places offending labs at risk when the numbers vary (which they often do as labs seek payment from payers).
It’s as if labs are forced into self-limiting shackles in an attempt to avoid an audit but also makes them break the shackles by just seeking proper reimbursement for their testing.
Then, once you find the balance between having your tests distributed at the right levels but also avoiding auditing attention, you then have to navigate the payers and their ever-changing processing habits.
To Pay Or Not To Pay: Insurance Company Difficulties
Insurance companies are still attempting to make your billing team lose their hair as quickly as possible, and that shouldn’t change any time soon.
Tensions have been rising between payers and labs for a time now, and the internal processes you implement are critical to ensuring your lab avoids lawsuits while receiving proper reimbursement at the same time.
What should you look out for?
One main aspect to focus on is which payers pay certain levels.
Ultimately, most payers shouldn’t bill above level 2 anyways since their coding policies often state confirmations are billable when inconsistent results are confirmed.
As an example, If inconsistent results are obtained the odds are that very few patients will test positive for 15-25 inconsistent drugs at a time.
Therefore, the preparations by payers to avoid this rare occurrence have rendered level processing extremely difficult.
This doesn’t stop them, nor does it make your billing processes any easier when they send back denied claims.
Past this, certain payers will, as mentioned before, pay certain levels where others won’t.
Others will rely strictly on medical necessity requirements to be met before payments are made.
Now, insurer trends are shifting to where payers (often categorically) request medical records to establish medical necessity for higher level codes.
This then causes strain on your billers to either fax over medical records with each and every claim or to wait for the denial to then send records in the hopes that timely filing will be met.
Medicare Rules And Which Payers Actually Follow Them
Medicare has typically set a standard of which payers should follow, but in all actuality very few payers do.
Of the 4 largest national commercial carriers (Aetna, Cigna, Humana, and UnitedHealthcare) only 1 follows Medicare guidelines.
As a ripple effect from this fact, smaller payers follow the bigger payers and most vary in some way.
This trend means issues are thrown into your billing cycle through various methods.
Review the major issues below:
These typically act as the proverbial stick in the spokes of your revenue cycle.
Even when everything goes right when getting the claim out of the door, you still have issues with payers not doing what they say.
Take Medicaid of North Carolina for instance. Med. NC’s policy in 2017 stated they would only accept G0477-G0479 for screening.
However, midway through the year showed the opposite. They were only paying 80305-80307.
Many payers now are actually requiring pre-authorization for testing (which MCR does not).
This trend seem’s to be trickling down as most payers follow big payers (rather than MCR).
Major Takeaways for 2018 Toxicology
Aside from consistent headaches courtesy of payer insanity, many trends are continuing in the same direction.
- Medicare will push guidelines that are rarely followed well enough to optimize your billing cycle.
- Payers that adhere to their coding policies will rarely structure them with any cohesive strategy for your lab to process its claims.
- Then there are payers that will disregard their policies, and leave labs behind to play catch-up.
Expect trends to continue in their current direction.
While not the brightest point, knowing where the trends are going helps you adjust to them to maximize your revenue cycle.
The management is getting more and more difficult, and this leaves lab executives struggling to manage.
Follow our blog to keep your lab ahead of the curve on payer trends, lab management strategies to improve your revenue cycle!