May 23, 2016 | Compliance, Legal, and Malpractice, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology
By rethinking how their medical labs relate to health insurers, physicians, and patients, a handful of progressive lab companies are enjoying increased revenue while also lifting patient and payer satisfaction
There is widespread agreement across the clinical laboratory industry that it is becoming ever more difficult to have health plans reimburse claims for common tests, molecular assays, and genetic tests in a reliable and consistent manner. Many lab companies report that they are experiencing high rates of denied claims. Moreover—even for claims reimbursed by payers—the amount paid will vary on claims for the same type of lab test.
“Essentially, on this point, the consistent theme we hear from many lab companies—particularly those labs with a menu of proprietary, specialized molecular and genetic tests—is that it is now almost a crap-shoot to submit lab test claims to many payers and see timely and predictable reimbursement for those claims,” stated Robert L. Michel, Editor-In-Chief of Dark Daily’s sister publication, The Dark Report. “One could say that, today, the function of billing patients and payers for clinical lab testing has become financial quicksand for most labs. By following traditional coding, billing, and collection practices, in today’s healthcare market, they find themselves sinking steadily deeper in this financial quicksand.” (more…)
Apr 15, 2016 | Coding, Billing, and Collections, Instruments & Equipment, Laboratory Pathology, Laboratory Testing
Filing a complaint with the Louisville division of the District Court for the Western District of Kentucky, Exact Sciences seeks payment from Humana for at least 4,664 Cologuard tests as well as coverage for the procedure in the commercial plans offered in mandate states
Citing more than $800,000 in unpaid service fees and damages, the Exact v Humana lawsuit is the latest example of the on-going struggle between health insurers and clinical laboratories offering proprietary and patent-protected lab procedures.
Exact Sciences Corp. (NASDAQ: EXAS), and Exact Sciences Laboratories, LLC (Exact) allege that Humana (NYSE: HUM) has denied 120 claims in Kentucky worth approximately $70,000 as well as 293 additional claims in other states with coverage mandates worth approximately $169,000.
Exact claims that attempts to appeal denied claims resulted in payment for some services but that more than half remain rejected. They also report roughly 350 claims in which Humana underpaid.
They are seeking full payment for all claims made since the start of 2014 in Kentucky, Georgia, Missouri, North Carolina, Texas, Illinois, Nevada, and Oklahoma. (more…)
Feb 24, 2016 | Compliance, Legal, and Malpractice, Laboratory Hiring & Human Resources, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology
As reimbursement models shift, physician practice management companies (PPMCs) offer increased value and appeal for hospital-based physicians (HBPs)
Are physician practice management companies (PPMCs)—a hot trend during the 1990s—poised to make a comeback in this decade? Whether this healthcare business model can gain traction during the 2010s remains to be seen, but, of all physician specialties, pathologists are likely to be among the most skeptical, just as they were during the 1994-2000 heyday of PPMCs.
In the mid-1990s, such physician practice management companies as MedPartners, Phycor, and others raised billions of dollar to invest in both independent physician practices and hospital-based physician (HBP) groups. But not even 10 years later, competition for viable practices drove prices above sustainable levels and many PPMCs closed shop. (more…)
Jan 13, 2016 | Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Testing, Management & Operations
Recently-announced partnerships want to use big data to improve patient outcomes and lower costs; clinical laboratory test data will have a major role in these efforts
In the race to use healthcare big data to improve patient outcomes, several companies are using acquisitions and joint ventures to beef up and gain access to bigger pools of data. Pathologists and clinical laboratory managers have an interest in this trend, because medical laboratory test data will be a large proportion of the information that resides in these huge healthcare databases.
For health systems that want to be players in the healthcare big data market, one strategy is to do a risk-sharing venture with third-party care-management companies. This allows the health systems to leverage their extensive amounts of patient data while benefiting from the expertise of their venture partners. (more…)
Aug 21, 2015 | Coding, Billing, and Collections, Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology
Smaller clinical laboratories and pathology groups should benefit from shift toward consumer-driven healthcare
High-deductible health plans (HDHP) are increasing in popularity as more consumers opt for lower annual premium costs in exchange for larger out-of-pocket expenses. This shift in health insurance could result in direct benefits for smaller clinical laboratories and pathology groups as more patients have a choice in where they purchase medical laboratory testing services.
From a policy perspective, employers and healthcare strategists hope that using HDHPs to engage consumers will help put market forces back into medicine. Because clinical laboratories and pathology groups increasingly find themselves excluded from provider networks, and fighting to keep access to patients, they should welcome the trend to consumer-driven healthcare.
A logical response to the HDHP trend would be for labs to begin posting their lab test prices on their websites. It would be equally useful to also post quality-performance and customer-satisfaction survey results to allow consumers to make informed choices about the labs they want performing their tests. (more…)
