As laboratories continue to experience increased pressure from PAMA and governmental and private payers, end-to-end denial prevention strategies become critical in minimizing disallowed revenue and payment loss. With an average of 5-10% of claims denied for any number of reasons, and of those – only 35% are ever reworked and resubmitted, claims denials can account for a significant drain of revenue to the bottom line.
When you look at the five top causes of denied claims, you begin to see solutions often reside in seemingly unrelated functions, such as the patient access experience:
- Unconfirmed eligibility — including insurance verification, deductibles, and benefits
- Missing information — which includes prior authorizations, patient demographics, and clinical documentation
- Previously adjudicated services — lab tests or procedures that were already billed
- Duplicate claims
- Filing time limits expired
Front-End Solutions to a Claims Denial Problem
Whether your organization is a hospital-based lab that’s working in conjunction (or at the mercy of) hospital admissions departments, a reference lab, or a clinical lab, preventing claim denials starts with the information that’s initially obtained from the ordering provider. No question, a proactive stance in supporting solutions that work for the entire team leads to the reduction in claim denials you need.
By automating front-end data collection, verification, and follow-up, errors can be minimized to less than 1% using the following workflow solutions:
- Insurance Verification and Benefits Eligibility—automate this step and ensure that you have valid insurance information including:
- Eligibility dates
- Co-pays, co-deductibles, co-insurances
- Out-of-pocket amounts remaining and maximums
- Disallowed tests or procedures
- Patient pay estimations
- Prior Authorizations (PA)—with retro submission of PA’s becoming less and less successful, automating the up-front PA process not only significantly reduces unwanted denials, but also has a positive effect on workflow by lessening the stress and frustration of interacting with insurance payers in a time-consuming series of phone calls, faxing, and follow-up. With a PA remedy using artificial intelligence and machine learning, labs and their partners can:
- Determine if a PA is required, or not
- Initiate a claim and monitor its status
- Follow-up and verify, if necessary
- Forward completed, approved PAs directly for test processing or billing, as required
And this can be done with speed and accuracy while freeing staff to concentrate on the patient experience or the testing platform.
With lab denials on the rise and retro submission being denied more and more, it’s time to evaluate the ways that increased automation can streamline the revenue cycle management process and reduce possible friction with patients. A number of states will be deciding in November how “surprise” billing will be handled statutorily and it’s more important than ever to reduce transferring unpaid claim amounts to patients when they were avoidable with proper, clean billing techniques.
Contact us to schedule a demo on prior authorization and insurance verification enhancement for laboratories.