Toxicology Labs

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.

Coding

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. 

Accounts Receivable

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

Patient Collections

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.

Compliance

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.