Thanks to an ever-changing CMS landscape, U.S. healthcare leaders are searching for new ways to maintain fiscal health and generate patient value. As payment rates continue to be slashed year over year, laboratories have proven to be significant sources of revenue – with the proper solution.

As part of its Protecting Access to Medicare Act, CMS experienced a 10 percent payment rate reduction for clinical testing in 2018, according to the American Medical Association. Unfortunately, those cuts are just the beginning. An additional 35 to 45 percent reduction in payments for tests typically performed at physician offices are expected over the next two years – a 10 percent reduction in lab reimbursement in 2019, followed by another 10 percent reduction in 2020.

Prior Authorization is Opportunity

As in many other areas of the healthcare system, securing a prior authorization has been a time-consuming source of frustration for labs and creates some complex challenges. A lab’s payment lifecycle begins with the prior authorization, and the hours of staff follow-up required to deal with prior authorizations adversely affect your bottom line. Receiving a prior authorization approval after a lab test is performed isn’t a viable solution since you run the risk of performing an uncompensated test.

Receiving a prior authorization approval prior to administering the test is critical to preserving revenue. Processing a prior authorization manually specifically for genetics and molecular testing often creates lost or delayed authorizations, decrease in patient satisfaction, and higher denial rates. Labs that have complex CPT codes often create significant challenges in gaining prior authorization approvals, since you can’t complete the test until the approval is received.

What are you doing to offset these recent payment rate reductions and decrease your denial rates?

Best Workflow Management with Exception Handling Specialists

Infinx supports interoperability that can help labs overcome challenges presented by new reimbursement models. How? By establishing best practices and optimizing workflows. Our solutions help you get ahead of the revenue cycle problem by quickly authorizing prior to testing and confirming every test rendered can be billed with certainty and propensity to collect.

Infinx Patient Access Software is a stage-oriented, comprehensive software that ensures a >95% successful authorization rate, a >99% accuracy rate, and 100% accuracy and adherence to a 24-hour TAT, enabling you to capture more revenue for your lab. A software system needs to be able to do the following:

  1. Case Preparation: Cases are prepared by researching relevant codes, patient history, symptoms, and prerequisites.
  2. Address Payer Questions: Payer questions are answered to justify the lab test.
  3. Address Complex Cases: Difficult cases that require multi-layer questions are handled by obtaining additional information and documents that are either with you or the physicians.
  4. Prior Authorization: Prior authorization and important case details are obtained.

But no system is 100 percent automated because you need both automation and expertise to fully automate your prior authorization process and reduce costs. That’s why Infinx retains a specialized prior authorization support team to handle exceptions as they arise. For example, if a patient’s benefits suggest a prior authorization isn’t required but the software indicates that it is, our team can evaluate the payer rules and the data feed to determine why there might be a discrepancy, all within 30 minutes.
Infinx’s deep understanding of claims processing and denial trends helps your team get answers quickly at each stage of the prior authorization process. A systematic approach like this one is not only key to understanding your prior authorization process, but also in determining training needs, identifying areas of revenue leakage, and creating preparation plans to react to state and federal regulatory changes in productive ways.

A Prior Authorization Solution Today

Automation is inevitable and the entire healthcare industry is moving toward patient-centered care, and your lab’s revenue cycle will have to follow suit. Infinx excels at providing process management for laboratories with a prior authorization that features:

  1. Real-time Data You Need Now. Automate your prior authorization and get the accurate data you need immediately.
  2. Exception Handling. Cases that cannot be automated are handled by prior authorization experts who are deeply knowledgeable on payer guidelines and protocols.
  3. No Auth Required Decision Engine. Get immediate results to determine whether or not an authorization is required, which is designed for scale and accuracy.
  4. Seamless Integration. Options are provided to view information in a web portal view, or seamless HL7 integration with your existing LIS.
  5. Extensive Payer and Clearinghouse Integrations. Extensive payer and clearinghouse integrations for a robust coverage of your insurance eligibility needs.

Infinx’s Patient Access Software optimizes your prior authorization workflow, minimize denials, and maximizes turnaround time. Exceptions are automatically routed to a team of certified prior authorization specialists, who are trained in laboratory prior authorizations, and can successfully complete your request on time. Automating your lab workflows ultimately frees your physicians and researchers time to focus on precision medicine, which adds value to both the lab and the health system it serves.

We don’t want you to just take our word for it though. Schedule a demo today and learn how our prior authorization software solution can simplify your workflow and increase cash flow in your laboratory.