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Friday, July 19, 2024

FrontRunnerHC - Shortening the Long Road to Reimbursement Starts with the Right First Step

Things are tough out there for labs and other healthcare organizations. Reimbursements have been declining. The Inflation rate and expenses are rising. And finding and keeping staff can be a full-time job. It all adds up to a perfect storm that makes reimbursements – whether from insurers or patients – harder to obtain. The financial squeeze is tighter than ever. You can’t afford to forfeit or delay any revenue you’ve earned.

Organizations must also be wise that patients, frustrated by often-confusing medical bills, are taking a line from that famous song and are “not gonna take it anymore!” What they will take is their business to another provider who makes sure the entire process runs smoothly.

A Smooth Process Starts with a Clean Order

Getting a clean order with the right clinical and financial information for the patient upfront is the key to maximizing reimbursement as it will help lead to a clean claim. It’s also critical to patient satisfaction. Happy patients tend to return, and they also lead to happy healthcare providers who are likely to send more referrals your way.

So what stops a clean order? The three biggies we often see are issues related to inaccurate patient information, prior authorizations, and medical policy. Data – a common denominator in each of these issues – is considered the world’s most valuable commodity. But data is only good if it’s accurate; it won’t provide much value to you if it’s not.

Inaccurate patient data

Inaccurate patient insurance and demographic information is a common problem. Each month in the United States, it’s estimated that more than 2 million people switch health insurance plans. Think about that! Each time someone switches plans, the prior data becomes obsolete. Bad information can result in significant delays in reimbursement, or even worse: forfeiture of the revenue. And your staff likely spends time they do not have trying to chase down the right info with the physician, resulting in lost productivity or potentially lost referrals from physicians irritated that they or their staff are wasting their precious time tracking down the missing data you’re requesting.

Prior Authorizations

Clean data includes having access to information that informs you up front if the patient needs prior authorization before undergoing any tests. Missing prior authorizations are one of the major causes of denied claims. I’d estimate that about 40 percent of physicians have staff who work exclusively on prior authorizations.

The consequence of that missing authorization can spread beyond the denial of the claim. It’s possible that while the lab is working to obtain authorization from the physician, the collected specimen could lose its viability, negatively impacting you as well as the patient who is asked to undergo an additional test or possibly opts to forego it. A survey by the American Medical Association (AMA) on the impact of the current prior authorization process found that 93 percent of physicians reported care delays and 82 percent reported that it can sometimes lead to patients abandoning the recommended treatment.

Medical Policy

Medical policy issues like a missed diagnosis code or those that result in a wrong test being ordered can also hinder a clean order and have vast implications for everyone involved. For the patient, it can mean delayed care, added worry, or a billing headache. For the lab: an unreimbursed service and wasted time and resources. For the physician: a stall in the delivery of care, an upset patient, and an administrative hassle.

“If you solved it on the front end, most of the issues would be gone.” – a quote from most everyone we talk to.

The traditional billing and reimbursement approach has often focused on the back end, seeking to find and fix errors through often cumbersome, manual, and lengthy efforts. By this point, the service was already rendered, or the test provided, and the patient may have even forgotten about the appointment. Payment and patient satisfaction are at risk.

Many are now rethinking that traditional approach and looking to technology to catch and fix issues before they become problems. Getting accurate patient data upfront can help mitigate the three big issues and pave the way for a clean order and a clean claim. It not only can help patients get the right test at the right time and pay the right amount, it can also help labs focus on running tests they can get reimbursed for. Leveraging data automation appropriately to get accurate patient data at the front end is key to your lab’s survival and growth. It can help simplify your workflow, remove roadblocks, and improve your bottom line, staff efficiency, and repeat business.


John Donnelly, CEO



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