Adventures in Laboratory Billing: Will the Forces of Negativity or the Good Guys Prevail?

A simple overall premise: you, the laboratory, are the “good guys.” You’re performing tests and analytics on patients who need them, since virtually no one engages with you because they have nothing else to do. No one decides, on a whim, to get their blood drawn (or whatever).

Sure, there may be some patients who want to see how their platelet numbers are doing, but really, you could probably say +99% of your patients either have orders for tests, or they’re getting tests as part of being hospitalized, or it’s needed occupationally as part of their employment. Regardless of whether it’s one of those reasons, or even if it’s because the patient wants a test for something electively, you’re the good guys. You’re the ones performing the tests and providing the analytics. You’re not forcing yourselves on them; they need you.

So, what’s the problem? Those on whom you depend for payment are often the “bad guys.” And remember, that can - and often does - include patients themselves. How terribly unfair! You do the work, you provide the results, you expend your time/effort/resources all in good faith, and then WHAM…you end up with two forms of A/R: (1) acid reflux because you have (2) accounts receivable.

A dual payer world: Your accounts receivable can be the result of (1) insurance payers who aren’t reimbursing and (2) patients who aren’t paying their responsibility balances. In other words, you can be financially beaten up on two fronts, although most complications come from the insurance side. For example, if you’re a pathology laboratory and if your splitting of TC/PC and the global charges by the payer are off, and if national/local coverage determinations aren’t being respected, you won’t be paid.

Here and Now/There and Then: Examples such as TC/PC are here and now, but what about there and then? Well, a major insurer (ok, it’s UnitedHealthcare) recently announced it will issue pre-claim audits for certain tests at some point. In other words, claims for those tests would be held up and perhaps not processed at all until you provide the required documentation supporting those claims. So, in addition to everything you need to do now to get insurance claims paid, you’ll also need to prepare for upcoming requirements, such as the one described.

How the Good Guys (you) can prevail: AI, AI, and AI to combat insurance payers’ own AI, which, according to many, is designed to find thousands of ways in nanoseconds to not pay. Your AI – or the AI used by your outsourced RCM vendor – must be solidly proactive for what’s happening right now and be on top of upcoming issues. Here’s the rundown on what your laboratory will need to overcome the “forces of malevolence:”

• eligibility verifications in advance to ensure patients actually have the coverage presented
• out-of-network alerts in advance to avoid surprises on the part of everyone involved
• a patient responsibility estimator (also excellent for avoiding surprises)
• automated prior authorizations whenever they’re needed, with an emphasis on “automated”
• proactive denial alerts giving you the upper hand by avoiding them in the first place
• NCCI alerts when multiple claims for a single patient should be bundled into a single master claim
• a quick way to edit/resubmit any sporadic denials not yet detected in advance
• real-time claim tracking to ensure your submitted claims are being processed by their payers
• intelligent alerts on claims that should’ve been paid by now by those payers, but which are still pending
• interactive balance-due reminder texts, emailable patient statements, and an online payment portal
• an accurate insurance discovery option for patients with no coverage listed or where it’s incomplete

Maximizing Revenue: Greed is Good! Ensuring - or even guaranteeing - you’ll be paid by insurance isn’t enough. You’ll want to capture maximized reimbursements by having claims coded for the best returns possible, without, of course, over-coding. Your outsourced RCM service or in-laboratory billing platform should code for optimized reimbursement.

Recap: You’re the “good guys.” You’re doing everything correctly (hopefully!). You should be paid for what you do, but unfortunately, the other side, in the form of insurance payers and patients, may not see it that way. All you can do is protect yourself to the extent possible, with AI on your side as well. If you do, you’ll not only succeed, but thrive in 2026.

ADSRCM supports laboratory clients with outsourced billing/analytics services and staffing. We’ll guarantee to increase your revenue in 90 days, and our behind-the-scenes team can help consolidate your in-laboratory staffing. Alternatively, the same AI/rules engine-driven platform we use – MedicsPremier – is available from ADS if in-laboratory automation is preferred.    

Contact us at 844-599-6881 or email info@adsc.com for more about outsourcing with ADSRCM, the MedicsPremier system, or both, if you’re unsure about your laboratory’s best approach. We’ll help you drive revenue and productivity in ways that work best for you!