In this first issue, we review several lessons learned on how laboratories must capture all available revenue and at a lower cost, even with continued reimbursement compression, due to PAMA (Protecting Access to Medicare Act) and payor contractual reductions.

Top Five Diagnostic Laboratory Lessons Learned on How to Accomplish This Include:

1. Automation is key to obtain accurate and timely information to create, transmit and receive payment for clean claims and reduce costs.

2. Alerts and data requirements “stops” built into not only the RCM billing and financial software, but more importantly, the laboratory order entry system to capture demographics, insurance, requirements and payor guidelines at the front end of the process.

a. Comprehensive, real-time eligibility and benefits– to obtain the correct and relevant insurance information for each patient and each encounter

b. Pre-authorization- in the last two years, laboratory pre-authorization requirements have increased substantially. If payor requirements and authorization approval is not captured prior to the test being processed and results released, it is too late

c. Consistent communication with ordering providers with Pre-Authorization guidelines and needs are an important part of this process.

3. Payor Contract review and re-negotiation– Payor contracting is a challenge for laboratories, which is driven by large laboratory competition as well as industry reductions. The past, traditional contract philosophies, based on a percentage of “current year” Medicare allowable are no longer sustainable with PAMA reductions of 10% per year beginning 2018.  The PAMA data collection and rational is being challenged in the courts, but the current reimbursement decline continues. Laboratories need to review and re-negotiate with payors based on a defined fee schedule.

4. Patient Collections – The patient’s responsibility percentage continues to increase each year. With a laboratory industry average bad debt percentage of 10-12%, this loss of revenue now becomes significant.

5. Focus and Tools – must be in place to capture this revenue more efficiently.

Some examples to assist with the capture of this revenue are:

a. Secure websites for patients to access current balances and pay online

b. Digital link to statements available via email and or text

c. Outbound automated dialer systems for payment reminders

d. Call center availability. The personal touch and availability of someone to answer questions is still important. There are still many patients that are concerned about payments via technology, you do not want to lose the revenue due to the non-availability of individual representative.

Lessons Learned: Diagnostic Laboratory content was provided by Jan Gunter, one of RoundTable’s Senior Revenue Cycle Interim Leaders, who has been an integral part of team for the last year. Jan has worked in the healthcare industry for over 30 years, 17 of which in leadership roles for nationally recognized organizations. With a primary focus on Revenue Cycle Operations, Revenue Integrity and CBO/SBO implementations, she blends strategic initiatives and business philosophy with industry standards and solution-based methodology tools to improve financial results for clients.

Her expertise in EMR/Software applications and regulatory knowledge provides our clients an excellent resource for implementing operational improvements and strategies significantly impacting cashflow positively.

Recently, Jan worked with a client implementing a Denials Management program in conjunction with design and implementation of their operations and workflows. She developed benchmarks and metrics to guide leadership in monitoring financial and operational status, long term. The outcome of this project showed measurable decrease in AR by an average of 27.5 days across the organization by means of cash collections, operations and technology efficiencies, not through write-offs.

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The challenges that providers face is a domino effect that results in difficulties for patients to schedule appointments at the time of need, at a convenient location and with their provider of choice.  When patients end up getting an appointment, they find themselves waiting in the office long after their scheduled appointment time to be seen. Worst of all, when they are finally seen, the provider briefly speaks to them and is forced to rush off to try to stay on schedule or spends their time hidden behind a computer screen and not focusing on the patient. The patients feel rushed and not connected to their providers, all of which leads to a poor patient experience.

These experiences do not necessarily represent all provider and patient experiences, but it does speak to the opportunity for improvement around provider fatigue and the patient/consumer experience.  A critical step in both is solving for Access. RoundTable Strategic Solutions has developed and successfully implemented Access and skill optimization strategies to address these specific problems. Combining lean principles of workflow optimization with standardization and centralization, the RoundTable team of experienced healthcare experts is focused on assisting organizations to drive revenue, optimize existing technologies, engage patients, develop the appropriate customer experience model, improve physician efficiency and experience, and drive the appropriate venue of care. “Right patient, Right care, at the Right time.”

Need assistance in solving for Access?  We welcome you to contact us today to learn more about this strategy and its results.by emailing our team at OurSolutions@roundtablehit.com.

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