“Super-clean orders”—those that not only include accurate patient data but also ensure that ordered tests will be covered—have the power to transform healthcare.
Two panels, which included five healthcare leaders, as well as the author of this article as moderator, recently discussed a variety of issues relating to the topic of clean claims:
In the Boston panel:
- Rick Hood, healthcare executive consultant with extensive experience in the healthcare and lab space
- Mike Snyder, executive vice president, Network Solutions, Avalon Healthcare Solutions
- Barry Wark, PhD, co-founder, chief strategy officer, Ovation.io
In the San Diego panel:
- Matt Collins, CEO, MedLab2020
- Ryan Hortin*, vice president, Revenue Cycle, Myriad Genetics
The panel discussions covered a lot of ground, such as the value of super-clean orders, the challenges that prevent clean orders, and the collaboration required to consistently achieve them.
Though the discussions happened on opposite sides of the country with different panelists, each group came to a similar conclusion: having a super-clean order up front benefits everyone involved, including the lab, provider, payer, and patient. And regardless of the role in the lab order continuum, each panelist seemed excited and willing to work together to make super-clean orders the standard, rather than the exception.
While the panelists and the audience likely came away with their own key takeaways, here are five highlights with some of the many thoughtful comments from the panelists included:
1. The silos that often exist between various parties across the healthcare spectrum challenge the ability to achieve a super-clean order.
Hortin expressed that “a potential lack of alignment in their interests is part of the sticking point when it comes to defining a clean order. A patient, for example, wants to know their results are accurate; a payer wants to know the test is medically necessary.” He added, “Friction comes about as a result of the lack of information, and it impacts the lab, the provider, the patient, and even the payer.”
“We’re a bit of a disenfranchised industry with a sometimes-adversarial environment,” commented Hood. “Clients get mad at labs. Patients get mad at their physicians. All because the correct information isn’t being captured up front.”
Collins referred to friction caused by integration challenges. “The patient intake systems that ordering providers use on the front often don’t match a lab’s data solution. That inconsistency can cause issues on the back end, especially when it comes to billing.”
2. The current process to get a super-clean order and comply with medical policy adherence and prior authorization is complex, broken, and burdensome.
Wark compared the healthcare ordering process to other industries. “The traditional workflow in healthcare doesn’t support the kind of feedback loops necessary to collect and revise information on an order once it comes into the LIS [laboratory information system]. Think about checking out an order on Amazon; they are sure to get the billing information right up front. In our industry, we put a lot of effort ensuring the clinical data coming in with the sample is correct but too little effort making sure the reimbursement and transactional information associated with that order is correct.”
Snyder shared that “one of the biggest challenges is that labs don’t know what needs prior authorization until the order hits their lab.”
Hortin noted, “First, there is some variability in whether health plans require pre-authorization. Second, when they require it, oftentimes they want it submitted within two days of sample collection. So, the lab’s collection date of service can look inconsistent with the date of pre-authorization and that creates confusion.”
There are similar frustrations with the process when talking with medical groups. In a separate conversation about this topic, a physician shared that he felt providers are often in the dark. “Which test do I order? What’s going to be reimbursed through insurance? How much is the patient’s responsibility?” He wants to know that he is ordering the right test. And he wants to know in advance if he is ordering the wrong test and the claim is going to get rejected.
3. The current process negatively impacts all involved: labs, providers, payers, and patients.
Hood estimated that back-end denials can cost a lab 20 to 30 percent in claims and up to 60 percent of the time staff spend tracking down patient info. “It’s far more expensive and far more time consuming to collect the insurance and medical policy information at the back end, and in a lot of cases, there’s no chance in collecting at that point.”
But currently, as Wark shared, “It’s very hard for labs to implement a workflow with your providers that doesn’t ruin their day, your day, and the patient’s day.”
The patients certainly feel the pain too. The physician mentioned above said, “We’ve got upset patients calling because lab tests aren’t covered.”
Hood and Hortin discussed the manual approach labs often take “to call the physician to get the right patient information.” It means “disrupting the physician’s busy day,” said Hood. And Hortin added that “physicians may not remember the particular test or may already have their test result so they don’t necessarily have a strong interest in helping you. The provider can view your call as a pain.” In a similar vein, Wark noted, “Every time a lab has to go back to the ordering provider, it’s a burden on the provider. It’s one more reason they might go to a different lab in the future.”
Collins said his team sometimes searches for missing information by trying to reach out to patients directly via outbound phone and text, after working with providers to incorporate patient-consent language, but acknowledged that the approach has challenges, calling it a “quasi-solution.”
Snyder may have surprised some when he said the current process causes pain for payers too. “The vast majority of payers want to pay claims efficiently. Remember that payers are a fiscal intermediary. They take in money for those members—such as a Medicare Advantage Plan or an employer group—so they are accountable for those dollars. They have to put administrative rules and tools in place. It is costly for payers to have to rerun or research claims and deal with appeals or reconsiderations.” He added that “appeals count against their [Medicare] Stars rating so a clean claim is actually an upside for the plan.”
4. Systemic change to consistently achieve super-clean orders is not easy but worth the effort.
Citing Conway’s Law, Wark acknowledged that systemic change is hard but possible. “In healthcare, we have silos that are not always aligned. But we have an amazing opportunity here.” He referenced “the ideas coming out of this panel discussion” and the “work being done to aggregate data and make a lot of these solutions possible.”
While Hood had previously shared the potential to increase reimbursements by reducing claims denials and enable staff to work on higher-value efforts with a super-clean order, Wark echoed the time savings. “The cost of fixing information at the back end versus fixing information at the front end is significant. For claims, information that comes in correct the first time takes labs less time.”
Most importantly, a super-clean order benefits patients, which is the number-one priority for everyone. To paraphrase something Snyder has said before, patients will get the right test at the right time and will be charged the right amount.
The right test not only benefits the patient but society as a whole. There is an opportunity to save billions by eliminating tests that have been ordered incorrectly.
5. The commitment to collaborate to address the problems that hinder a super-clean order is refreshing and energizing.
These panel discussions are a reflection of the conversations that are now taking place and a new level of collaborative efforts underway with payers, providers, labs, and patients. Together, industry leaders are driving change.
“A clean order means everything,” said Hood at the end of the panel discussion. “It’s critical for all of us to improve the relationship. It will help everyone involved. And labs want to cooperate.”
A common theme to fix the current process involved front-end transparency of all the required information and access to the appropriate data through an expanded use of technology up front.
Snyder added, “It’s not about us versus them. It’s about getting the right tools that are amenable to the workflow. Getting detailed patient information correct up front is incredibly important. With all the labs out there and all the different payer plans, plan types, and requirements, labs connecting individually with each plan is not viable. We need transparency around the policies and up-front access to insurance eligibility information, including coordination of benefits. We need tools to help one another understand the required information and any changes to plan policies. I’m encouraged that there is a desire to come together to integrate and develop the solutions at the front end.”
The involvement as moderator in these recent panel discussions reflects the desire to collaborate with these healthcare leaders and all the players across the industry to create a connected ecosystem, leveraging innovative technology to consistently achieve super-clean orders that benefit everyone.
*Ryan Hortin mentioned at the start of the panel that his comments are not necessarily attributable to his employer but represent his own 15 years’ experience in the industry.
The original version of this article was first published on the FrontRunnerHC website under the title, “It’s time to disrupt healthcare with a super-clean order.” It has been republished here with permission and slight edits to align with G2 Intelligence’s editorial style.
John (JD) Donnelly is the CEO and founder of FrontRunnerHC, which provides a data automation platform to help labs, hospitals, physician groups, and other healthcare organizations maximize reimbursements while also enhancing their patients’ experience with instantaneous access to accurate patient demographic, insurance, and financial information at any point during the care journey. JD will be kicking off G2 Intelligence’s June 2023 Lab Institute Virtual Event with his June 13 presentation, “Thriving in a Difficult Economy: Patient-centric Strategies That Will Improve Your Bottom Line.”