It has been 15 months since the No Surprises Act went into effect (1/1/22) and the country’s labs are still reeling with the fallout—along with the ongoing challenges of higher volumes, staff shortages, and huge revenue pressure.
S&P Consultants has been helping lab directors find ways to cope with evolving enforcement, payer backlogs, and conflicting guidance—ensuring efficient and compliant operations using legacy LIS tools, or upgraded solutions, as needed.
From what we’ve been hearing in the real world, these are some of the big questions that can help get lab directors back on the right track for 2023 and beyond:
REVENUE MANAGEMENT
1. How can our lab best avoid the claims processing backlog?
Last summer, the Independent Dispute Resolution (IDR) set up by HHR had a backlog of more than 90,000 claims and as of January 2023, only about 4% of these had been paid. The best way to avoid extending your accounts receivables, then, will be to avoid as many disputable claims as possible. Doing so means accounting for more payers (and their preferences) than ever before. Getting some help from consultants with a variety of national payer experience is a smart investment in view of the alternative.
2. What are some ways to accelerate reimbursements/revenues?
Establishing workflows and IT infrastructure that generate clean claims is a must. Giving your core systems (LIS, EHR, RevenueCycle) a tune-up can be a great start. Getting some advice on current best practices can be critical to understanding the many nuances for billing lab codes (both professional and clinical.) Having some well-considered additional rules built into your RCM can help you avoid the common gaps and mis-coded services that will delay your reimbursements.
LIS/TECHNOLOGY ISSUES
3. Are there ways my legacy LIS solution can be updated for No Surprises?
In most cases, a solution implemented within the past 5 years can easily be adapted to meet NSA requirements (e.g. no balance billing) provided the team making the upgrades has technical, clinical, and revenue expertise. Of course, for older solutions, NSA may provide the justification you’ve been looking for to convince senior management to modernize your systems.
4. What can our lab be doing better from a coding/revenue-capture standpoint?
Understanding all the rules your solutions need to accommodate is a great place to start. You need to know, definitively, which providers count you as in-network or out-of-network. This is especially important for pathology billing and 3rd-party contracts for surgical services where the pathology group may not be considered in-network even if the health system where the surgical procedure is performed is. Simultaneously, you need to be able to easily notify patients of complete expected charges. These estimates must be accurate in accounting for all services—not only technical but professional lab services as well.
NSA provisions can be different state to state, as well as between self-insured and group plans. In some circumstances, you can have a bill that is partially governed by state law and partially governed by the No Surprises Act.
THE BIG PICTURE
5. What’s on the horizon for enforcement? (And can I get any help?)
According to a major laboratory billing provider, “Bills for clinical laboratory services have notably remained a source of continued surprise billing. Issues still exist around the parameters of when the law is in effect and circumstances when it contradicts itself.”
Enforcement for the “Good Faith Estimates” (GFE) provisions of NSA has been delayed, for example.
Two lawsuits last fall successfully challenged the IDR process and further court actions may be expected in 2023. It’s important to have a trusted advisor who can keep you current.
And, yes! If you are looking for consultants that can weigh-in with authority and experience, we invite you to call S&P Consultants for some of the practical and candid advice we’re famous for.
HELP IS AVAILABLE
If your IT group is struggling to perform under remote-only conditions or due to resource losses (from budget cuts or illness) we welcome you to contact S&P Consultants for help. Our people have the kind of real-world experience that allows for hyper-efficient interventions—often performed remotely—with broad expertise across dozens of installations like yours. Our dedication to doing right by our clients has earned us recognition by KLAS including a 2021 “Best in KLAS” Award for Implementations requiring eight or fewer resources. Learn more.
