The reimbursement landscape for clinical labs has never been so challenging or so precarious. Patient and third-party payer responsibility continues to shift and there is no end in sight for continued changes and increases in government regulations and insurance requirements.
In a rapidly changing and consumer-centric healthcare payment lifecycle, diagnostic labs and more specialized labs focusing on outpatient genetic and molecular laboratory tests are at a unique disadvantage by the very nature of the service they provide. They find themselves scrambling to manage retro authorizations in an often manual and cumbersome manner.
New advances in Artificial Intelligence (AI) and machine learning in the patient access and Revenue Cycle Management (RCM) arena are answering many of those dilemmas and putting labs back in the driver’s seat.
How Advanced Automation Improves Retro Authorizations
Bridging the lack of face-to-face contact is priority number one. Laboratory reimbursement is complicated by the fact that they receive and test specimens without ever encountering the patient. This leaves the clinical lab in a passive role when ascertaining patient demographic and insurance information—relying on the hospital or the ordering provider to initiate prior authorizations and adequately verify insurance coverage.
When there has been no advanced request for prior authorization approval, the lab is left to request a retro authorization which often includes time-intensive follow-up. This back-tracking is often done manually with multiple phone calls, hold times, and faxing back and forth.
Then receiving a bill, a patient may have never heard of the clinical testing facility. This creates confusion with unexpected bills denied by their insurance for reasons they don’t understand. It then falls to the overburdened lab personnel to follow up with the ordering provider and gently coax their participation to help resolve outstanding claims issues.
Automated Retro Authorization
The sheer volume of claims and low dollar collections required in the diagnostic lab industry can be overwhelming. With the cost to collect relative to revenue being so high, it is paramount that labs streamline the process of identifying prior and retro authorization requirements for each patient quickly.
Ideally, labs have the ordering provider’s attention during accessioning and that is the prime time to determine what is required and to elicit their help if necessary. If there is something questionable, then they must initiate resolution immediately with the ordering provider or hospital.
For the diagnostic provider, using advanced automation with AI through a unified interface, patient information can be submitted directly to the insurance payer electronically, with all follow up being automatic. Any complex requests or exceptions would then be handled by trained specialists ensuring an overall increased completion rate and a significant reduction in claims denials.
Whether using a proactive or retroactive approach, prior authorizations can be processed and submitted with a workflow that saves valuable staff time and resources. Retro authorization becomes far less of a problem when integrated with the Laboratory Information System (LIS) where diagnosing providers can be enlisted to help streamline the prior authorization process.
Retro Authorization Also Improves Claim Denials
Diagnostic lab providers are required to participate in all or most of the insurance plans in their area if they want to compete in today’s healthcare market. With that comes very complex rules and regulations and the expanding opportunity for claims to be denied. The sheer volume of accounts receivables continues to grow for most labs as patient responsibility increases.
By bringing in an AI-driven, machine learning system to tackle retro authorization, you lessen the need for follow-up of claim denials. This ensures resolution to maximize bottom-line results.
Technological advances are now available allowing machine learning to lead the way on tackling healthcare’s most pressing reimbursement issues including retro authorizations. AI can reduce clinical labs’ pain points to a minimum by simply incorporating electronic solutions and supporting that with human intelligence when exceptions exist.
Book time today to talk with our team about prior authorization and denial management solutions that will improve your laboratory and pathology reimbursement.