LAB MANAGEMENT :: RCM
Enterprise vs. purpose-built lab RCM systems Considerations for lab directors
By Lâle White and David Nichols T
he laboratory industry has experienced tremendous change in the past few years. New compliance obli- gations and continued fee compression place an eco- nomic burden on many labs. In an attempt to save money, some labs—in particular those associated with hospitals and health systems—are using an enterprise revenue cycle management (RCM) module that is offered as part of the hospital’s electronic health record (EHR) software. This article explores what lab leaders need to consider when it comes to the capabilities of enterprise RCM systems vs. those purpose-built for laboratories. The health system may feel the enterprise RCM system is the most cost-effective option, but that fails to take into account the specific needs of the laboratory to maximize its revenue contribution and effectively manage compliance risk.
Compliance
The increasing complexity of compliance obligations for laboratories can seem unsustainable. In the first PAMA (Protecting Access to Medicare Act) data reporting period, few hospital labs were required to report. The definition of applicable lab has been adjusted, so many hospital lab leaders should be collecting the required data and preparing to deliver an accurate dataset during this second reporting period.
Although the definition of appli- cable lab has been modified, it’s still unclear how many hospital labs will be required to report. Nor is it well- understood whether the additional data will have a meaningful impact. It is also unknown whether hospital labs
bills, however, has potential impact on many laboratories, including hospitals that provide no services related to substance abuse treatment.
There are things that laboratories can do within their billing and RCM processes to help with EKRA compliance. For example, laboratories need to review policies related to writing off co-pays and deductibles. Under EKRA, it is now a federal felony to write-off these patient responsibility balances as a standard of practice for private payors, as it already is under Medicare. This can be extremely difficult to do with an enterprise RCM, not designed specifically for laboratories.
For example, when a lab offers waivers and discounts, Failure to report PAMA data
accurately can result in severe penalties. Applicable labs that fail to report or report
incomplete or incorrect data
face potential penalties of up to $10,000 per day, per line item.
will be able to successfully distinguish outreach data from outpatient data, as is required. According to the American Hospital Association, it is a significant burden on hospitals to effectively distinguish this data and is especially difficult if the lab is using the hospital’s enterprise RCM system, as the level of detail required for PAMA reporting is often not collected. To properly support compliance requirements, labs need RCM and financial management technology that not only helps improve cash collections, but delivers visibility into and control over financial operations. Optimizing billing and accounts receivable processes, intelligently automat- ing workflow, facilitating claim and appeal filing, and removing clerical decision making also reduce regulatory compliance risk.
Payor billing rule changes
The most extensive change to payor billing rules of late is related to the Eliminating Kickbacks in Recovery Act of 2018 (EKRA). The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) is intended to address the national opioid crisis. EKRA, one of its accompanying
24 JUNE 2019
MLO-ONLINE.COM
these cannot be fixed amounts, nor have a stated upper limit. It cannot be a one-size-fits-all approach. There needs to be bona fide financial assistance counseling for each patient and attempts need to be made to collect on any balances due. This is especially relevant for hospitals using an enterprise RCM. Because the average in-patient invoice is dramatically higher than the typical outreach lab invoice, there is a tendency for many hospitals to allocate their collection resources toward the higher value balances, and therefore, smaller lab-based balances tend to be written-off.
A purpose-built lab RCM solution provider, with lab-specific operational expertise, can advise you on mitigat- ing the impact of EKRA by optimizing reimbursements and pursuing a sec- ondary payor strategy to further reduce the patient out-of-pocket. In addition, the purpose-built solution provider can also advise on taking the best
advantage of an organization’s data to formulate a strategy for maximizing the organization’s “in-network” footprint.
Data visibility
Another impact of running a lab on an enterprise RCM system is that typical enterprise RCM systems do not pro- vide the data visibility required to effectively operate a lab. Purpose-built RCM systems for laboratories use web services to deliver capabilities and information wherever they are needed across the system, including connections with patients and clients through portals as well as interoperat- ing with external systems. The best web services for labs have HIPAA and internet security protocols built in. It is also essential for labs that these two-way data exchanges operate in real time, removing redundancies and data latency. The information held within lab billing and information systems is useful and powerful. Diagnostic services influence most medical and therapeutic decisions, and the data from the patient’s medical record, most relevant for optimizing care, is also diagnostic data. Labs need to leverage these important data assets, but if they are using enterprise RCM systems, they may not be able to fully access, visualize, and thereby benefit from this valuable information.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48
