Laboratories are uniquely situated to benefit from the expanding technology available to strengthen their billing and AR systems. They must comply with advanced reporting requirements and, whether maintaining billing in-house or seeking a qualified third-party vendor, must stay up to date on continually changing guidelines and regulations.

The healthcare payment lifecycle for laboratories is multi-layered and complicated by virtue of its third-party payer system. There is no getting around that fact. Guidelines and compliance
expectations seem to change frequently and even though the pathologists are responsible for providing the service and for the patient’s care and outcomes, insurance carriers and regulatory
agencies define the overall process with little input from providers.

Lab Reimbursement and Meeting Insurance Billing Requirements

Reimbursement is directly affected by things such as timely filing, accurate coding, and deftly managing denials and accounts receivable. Whether pathology groups and laboratories are
stand-alone facilities or operate within a larger hospital system, there are key components of the healthcare payment lifecycle that offer tremendous opportunity for improvement when bringing
technology and automation to bear.

Medical Coding

Traditionally, labs have relied on coding to be done as a manual process by medical coders working for the laboratory or on behalf of their sister hospital system. With over 144,000 ICD-10
codes and 8,800 CPT and HCPCS codes, the opportunity for errors and denials are substantial and are estimated to be over 5% industry-wide, with a full 65% of those denied claims never
reworked and the revenue simply abandoned.

What’s needed is a scalable and cost-effective solution that’s automated and supported by human specialists that are AAPC-certified to maximize your reimbursement. Unlocking critical revenue hinges on professional coding services that are routinely audited for clarity and accuracy, non-specific diagnostic code and incorrect modifier avoidance, and reduced upcoding or unbundling of charges.


Once patient tests have been accurately coded to the highest level of specificity, then charge entry and claims submissions must occur in a timely manner. Each step in the healthcare
payment lifecycle relies on previous interactions to ensure success in properly capturing the full reimbursement due to the laboratory.

Failure to stay current on insurance carrier and governmental agency requirements and regulations is a leading cause of claims rejection, which slows down the billing process with denials and mismanaged submissions. It also puts the contracted carrier on notice that requirements are not being met or are at least falling short.

Whether a lab chooses to manage the billing process in-house or engage a valued third-party billing team, clean claims that are correctly coded and submitted on time should be the baseline
standard. Monitoring or auditing rejections and denials is the best way to ascertain if these guidelines are being met. If more than 10% of claims are being rejected, there is work to be done.

Denials Management and AR

When reviewing insurance billing requirements for labs, it’s important to examine the Account Receivable process and ultimately claim denials. For a large number of claims, payments are received and posted without incident. But for the 20-35% (per industry statistics) that are denied or rejected, these inflate your AR and take considerable time to follow up and resubmit.

Luckily, denials management can now be leveraged with AI and supplemented by certified billing specialists to bring advanced analytics and predictive insight to capturing every dollar
earned. By prioritizing workflow, effort can be focused on meeting requirements, efficient on-time follow-up, and resolution.

With the advances in technology for healthcare billing, laboratories and pathology groups can better position themselves to maximize reimbursement. Billing, coding, and denial management
requirements can now be met quickly and virtually error-free through Artificial Intelligence (AI) enhanced software supported by outlier resolution specialists.

Contact Infinx today to schedule a demo on medical billing and coding solutions.