Coronis Health, Hospital & Surgery Center
Toxicology is a rapidly growing specialty in the United States. Given the opioid epidemic, the need for toxicology testing and laboratories has greatly increased.
As specialty toxicology is the process of testing patients for illicit substances, along with testing to ensure they are taking the proper dosage of their medication, this type of testing is both qualitative and quantitative. Toxicology testing is generally utilized by pain management providers, general practitioners, family practices, psychologists, and psychiatrists. Due to the recent opioid crisis throughout the US, toxicology testing has become paramount in many providers’ treatment plans in order to diagnose, monitor, and assist patients.
The growing specialty of toxicology
Given the opioid crisis in the US, toxicology is a fast-growing specialty. The statistics are staggering. According to drugabuse.gov:
- Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them.6
- Between 8 and 12 percent develop an opioid use disorder.6
- An estimated 4 to 6 percent who misuse prescription opioids transition to heroin.7–9
- About 80 percent of people who use heroin first misused prescription opioids.7
- Opioid overdoses increased 30 percent from July 2016 through September 2017 in 52 areas in 45 states.10
- The Midwestern region saw opioid overdoses increase 70 percent from July 2016 through September 2017.10
- Opioid overdoses in large cities increase by 54 percent in 16 states.10
The toxicology billing process
The toxicology billing process is somewhat unique compared to that of other laboratories. This is due to the fact that it is a newer space within healthcare and because many payers abide by different rule sets.
The two major sets of rules are governed either by the AMA or CMS. Each organization has different sets of fees and panels which must be adhered to, and they each come with their own nuances. One example of this is demonstrated by the ability to bundle and unbundle drug classes based on the code set in order to maximize revenue potential.
Eligibility & Verification
Eligibility verification and prior authorization are also key. Since the toxicology space is newer and rapidly growing, many carriers are lagging behind in terms of their coverage and benefit plans.
Ensuring the patients are eligible for this type of testing and determining whether or not a prior authorization is required is paramount to the success of any toxicology laboratory. This is one of the largest determining factors between one that is profitable and one that isn’t.
The coding of the tests and how they are billed out is paramount, which we briefly touched on above. The AMA and CMS both set different coding requirements and fee schedules. The determination of which complexity of test to perform or the number of panels to test is critical in avoiding an audit or large payer refund requests.
AR follow-up also poses challenges within the toxicology space, mostly due to it being a newer procedure. Because of this, some claims are rejected or denied on the first pass and require additional manual inquiry via phone or appeals. In order to combat this, we assist in providing documentation that displays reasonable and medically necessary diagnosis under Medicare guidelines for all toxicology testing. We have processes in place to handle these items, and we are extremely experienced in appealing these claims and getting them paid
Collecting the patient portion of the balances that are derived from toxicology billing is crucial in a laboratory’s success. We have a massive amount of experience within this arena. Many balances are largely due to the complexities of the billing process, and procedures must be put in place to monitor and manage the patient AR. These items include, but are not limited to, patient discounts, payment plans, carrier negotiations, and claim appeals.
Anyone who follows the toxicology space has heard the horror stories of toxicology labs accused of fraud. From submitting false claims to kickbacks, toxicology labs have gotten a bad rap. In an effort to not get lumped together with the bad eggs, it is crucial for labs to maintain strict compliance. This, combined with the fact that toxicology is still a fairly new specialty with changing reimbursement guidelines, makes it challenging for labs to keep up and be compliant.
Schedule your free financial checkup and learn how Coronis can help you increase collections and improve cash flow.