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December 2025
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LAByrinth
Billing, Operational, and Staffing News for Laboratories
Presented by ADSRCM and ADS, Leading Providers of Outsourced Billing Service/Staffing or In-Laboratory Revenue Cycle Management Systems
Your ADSRCM 2025 Year-End Lab Revenue Briefing
A Message from Jim:
As 2025 draws to a close, it’s clear this has been one of the most financially complex and operationally demanding years the lab industry has seen in over a decade.
From payer price compression to the ongoing PAMA uncertainty, mounting denial volumes, and compliance burdens, labs are being pushed to rethink their revenue strategies—and fast. At ADSRCM, our job is to help you make sense of these challenges, find the missed revenue, and build sustainable billing infrastructure that actually works in today’s landscape.
This briefing outlines where things stand, what’s ahead in 2026, and the high-impact steps your lab can take right now to protect its bottom line.
Let’s take a closer look.
Jim O’Neill
Advanced Data Systems
PAMA & CLFS: Short-Term Relief, Long-Term Risk
The Protecting Access to Medicare Act (PAMA) continues to shape lab reimbursement policy in major ways. While 2025 brought a temporary pause to upcoming cuts, that pause came with an expiration date.
What was paused (effective Nov. 10, 2025):
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Up to 15% cuts to nearly 800 CLFS codes
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Private payer reporting requirements
Expiration: January 30–31, 2026
Without additional Congressional action—like the RESULTS Act—those cuts could kick in late next year. That’s why now is the time to model your exposure and prepare.
👉 Run a reimbursement impact review using your actual CPT/test mix.
Why Labs Are Seeing 7–12% Revenue Declines
Even with PAMA temporarily delayed, revenue headwinds worsened in 2025. Here’s why:
🔹 Payer Pricing Compression
Core codes are reimbursed at lower rates, and contracts haven’t kept pace with market conditions.
🔹 Increased Denials and Slower Response Times
Medical necessity edits, additional documentation requirements, and longer adjudication cycles have created significant cash flow bottlenecks.
🔹 Aging Contracts
Many labs are still operating under fee schedules that are 18–24 months out of date—without renegotiation clauses or rate escalators.
🔹 Volume ≠ Profitability
Doing more tests doesn’t guarantee better margins. Labs need to track reimbursement per payer, per CPT, per contract, not just volume growth.
👉 Ask about ADSRCM’s contract intelligence tools to uncover hidden reimbursement gaps—no extra software required.
The PAMA “Pause” Is a Window, Not a Safety Net
Don’t mistake this delay for stability. It’s a limited-time opportunity to:
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Strengthen denial prevention
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Tighten billing operations
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Negotiate smarter payer contracts
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Automate manual workflows
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Prepare for the 2026 CLFS and reporting cycle
Labs that act now will enter 2026 on stronger footing. Labs that wait may face avoidable disruption.
2026 Readiness Checklist: 5 Critical Areas to Review Now
1. Billing Cost vs. Net Collections
Benchmarks:
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In-house billing: 6–7% of net collections
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Outsourced billing: 5–8% (including software, staff, analytics)
If your current model isn’t producing 1–3% gains over baseline, it may be time for a rethink.
👉 Request a cost analysis based on your actual payer mix and CPT volume.
2. Billing KPI Performance
Your lab should be tracking:
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Clean claim rate: 95%+
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Denial rate: <20%
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Days in AR: 30–45
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Net collection ratio
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Revenue leakage by payer and CPT
Even 1–2% improvements here can mean tens of thousands in additional monthly revenue.
3. Scalability & Compliance Readiness
Can your current workflow adapt to:
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March 2026 CLIA electronic reporting transition?
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Molecular billing rule changes?
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AI-driven edits and prior auth logic?
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LIS-to-billing automation demands?
If not, it’s time to modernize.
4. Payer Contract Age & Rate Integrity
Ask yourself:
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Are your most-used CPT codes underpriced?
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Do your contracts have escalator clauses?
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Are plan types (HMO vs. EPO) reimbursing inconsistently?
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Are payer edits silently reducing your net rates?
👉 ADSRCM can run a contract profitability review to identify missed revenue opportunities.
5. Workflow Automation
Labs must reduce time spent fixing denials and chasing data. Top automation targets:
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Eligibility checks
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Prior authorizations
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Claim scrubbing
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Auto-posting
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Daily denial workflows
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LIS/EHR integration
Let your billing team focus on revenue—not rework.
Molecular Billing: The Highest Risk Area in Lab Revenue
Pathology and clinical testing face price pressure, but molecular billing introduces a whole new level of complexity. Revenue loss here is often hidden—and costly.
Key Risk Areas:
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Multiple CPT codes, stacking, taxonomy updates
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Incomplete documentation (progress notes, test orders, medical necessity)
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Missing prior auths or inaccurate LIS→billing data
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Region-specific rules (MolDX, MACs, Medicaid variation)
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Staff shortages and high turnover
We support molecular workflows with:
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Automated edit logic
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Documentation prompts
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Denial analytics
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Real-time claim validation
Your Lab’s 2026 Action Plan
Before January hits, here’s what we recommend:
✔️ Conduct a contract age + CPT rate review
✔️ Analyze denials for documentation and auth gaps
✔️ Audit billing team capacity and turnover risk
✔️ Evaluate cost-to-collect against collections
✔️ Map PAMA impact using your top CPTs
✔️ Improve LIS → billing automation
✔️ Find and fix revenue leakage now
✔️ Benchmark against clean claim, AR, and net collection goals
Closing Thoughts
2026 will be a defining year for diagnostic labs. The PAMA delay is a brief reprieve—but payer pressure isn’t going away. The labs that use this time to modernize, automate, and renegotiate will be positioned to thrive.
At ADSRCM, we’re here to help you:
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Optimize your revenue cycle
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Eliminate revenue leakage
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Improve compliance
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Scale confidently into 2026
We also offer a 90-Day Guarantee—because you shouldn’t have to guess whether a billing partner will deliver results.
Ready to see your custom roadmap?
We hope you enjoyed the read.
Contact us about outsourced billing/staffing services (ADSRCM), or about MedicsPremier as an in-laboratory platform from ADS. We’ll help drive revenue and productivity in ways that work best for you. 800-899-4237, Ext. 2264 or info@adsc.com.
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Next Up:
January, with new articles and items of interest for laboratories!
We strive to provide our newsletters with news of the current month, not the previous month.
We greatly appreciate feedback or comments on our newsletters/content. Please opine by emailing christina.r@adsc.com or by calling 800-899-4237, Ext. 2264. We’d love to hear from you!
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