Prior Authorization For Lab and Diagnostic – Overview

  • Rapid increase in spending for advanced diagnostics test orders
  • Clinical laboratory testing costs represent only 3 percent of total healthcare costs
  • Diagnostic testing influences 70 percent of all healthcare decisions
  • Payers are accelerating efforts to appropriately manage the utilization and reimbursement of molecular diagnostics and genetic tests
  • Revision of the coding system
  • More and more requirements to support the utilization of the test in clinical outcome
  • Rapid changes in reimbursement for advanced tests

Payer Coverage Decision

  • Is the test declared statutory exclusion?
  • Is the test being performed for a person that lack symptoms of the condition being tested?
  • If the person is asymptomatic—considered screening is NOT covered.
 Calculate The Imapact Prior Authorization Has on Your Practice

Calculate The Imapact Prior Authorization Has on Your Practice

Say Goodbye To The Misery of Obtaining Prior Authorization Today

Value Questions

Will genetic medicine:

  • Improve the quality, safety, and/or cost effectiveness of delivered healthcare?
  • Drive additional costs with marginal healthcare gains?
  • Is it likely to improve the outcome?

Ultimate Objectives

  • Right test, right patient at the right time
  • Identify duplicate or incorrect test orders
  • Avoid unnecessary charges
  • Maximize reimbursement

Critical Trends Impacting Reimbursement


Transparency & Collaboration

& Collaboration

Measure then Manage
Collaboration so that all
parties involved know
the answer to these

What Can Labs Do…

  • Create real-time technology link between clinicians, payers and other laboratories
  • Benefits Verification
  • Authorize all non-acute labs /apply machine learning
  • Critical thinking – move away from the assembly line
  • Distribute labor and system wisely
  • Manage payer utilization and relationship to gain insight into their requirements

Electronic Prior Auth Implementation

  • Review present workflow
  • Identify mundane and routine oversight
  • Re-engineer the process
  • Train people
  • Tie people, process and system together to simplify authorization business process.

Build System-based internal controls that prevent unauthorized tests

PracticeSuite Prior-Auth Process

  • Business Process Analysis:
    • Review present business processes
    • A/R analysis
    • Denials analysis
    • Review reimbursements and contracts
    • Review payer notification process
  • Align Process, People and System
  • System Control to Alert “Authorization Hold
  • Every test is billed
  • Fully integrated system: Clinical, Ordering, Billing systems tied to Payers
  • Single source of patient demographics
  • Ordering, LIS and billing data flows in real time
  • 3600 tracking of orders, draws, bills, denials, insurance payments and patient payments
  • Provide Approval/Denial from 2 hours to 5 business days depending upon the additional information request. Certain cases may take longer with certain state Medicaid payers, but they provide effective data prior to the authorization dates

PracticeSuite solution for Post Obama–Patient Responsibility Challenges

  • As part of the authorization, PracticeSuite Auth Reps collect accurate portion of patient responsibility
  • This information is sent back to PracticeSuite and back to the lab
  • Enables client to accurately collect patient portion at point-of-care

Closed Loop Authorization Process Flow

PracticeSuite Differentiators

  • Pre-authorization process begins prior to sample being drawn and/or before lab receives specimen
  • Guaranteed turnaround times built into contract
  • Trusted partner

– To scale the ever evolving need without having to scale internal staff
– Pre-Auth’s team is scalable as required by client (experienced with seasonality and growth)
– Stay ahead of regulatory and reimbursement changes with partnership and industry
– More approvals, less denials, and faster payments

  • PracticeSuite has over a decade of services to its clients
“With the RCM service, the dashboards are user-friendly, our client manager listens to our needs, and the workflow analysis is incredibly helpful.
We’ve been able to reduce our administrative workload by 70%.”
Lab Facility Naples, FL

Case Study

Client is a large multi-location hospital network. PracticeSuite with its partner 4Medica were called in to analyze overall lab operations and issues related to precertification. We noted the following business problems:

  1. Denials related to pre-authorization: $6MM annually.
  2. Lab did not have a way to prevent patient arrival for draw and test.
  3. Ordering physician related draws arrived and the lab tech performed the work.
  4. There was no process in place to auth genetics and molecular lab tests.
  5. Patient balances were collected after the fact resulting in large accumulation of patient balances, which were mostly uncollectible.
  6. There were some process challenges that prevented patient draws and tests when unauthorized.

PracticeSuite’s Authorization Desk solution offered the following solution:

  1. Identify lab tests that require prior auth.
  2. Run these tests through Authorization Desk to do the following:
    1. Upon receipt of order, notify patients of the receipt of order as text message: Welcome ______, we are in receipt of your order, for your convenience, we are presently verifying your insurance to obtain the necessary approval. We will contact you shortly with further updates.
    2. Upon approval, patient is notified to schedule an appointment or walk-in. Most importantly, if the pre-approval requires clinical records for medical necessity, we contact the lab coordinator to obtain these from the ordering provider’s office.