ABOUT

The client is an established pathology lab in Michigan.

CHALLENGES

1) Medicare partial payments. For certain lab claims, Medicare paid partially on the total units billed resulting in significant under-payments.
2) CLIA issues. Medicaid denied all claims due to expiration of Clinical Laboratory Improvement Amendments (CLIA) certification.
3) Insurance specific billing. Blue Cross Blue Shield Medicare Advantage Plan had different rules compared to other carriers and expected unique codes to process claims correctly.
4) Paid to patient collections. Insurance companies sent checks directly to patients whenever the lab had a non-participating status with them. Collecting from patients was a big challenge.

WHAT WE DID

Not only did our team work towards organizing the billing workflow for the lab, we specifically addressed the challenges faced by them.
1) We incorporated regular appeals to Medicare as part of the regular billing process, which resulted in complete payments for all partially paid claims.
2) We discovered the problem for Medicaid denials and coordinated with the lab to update Medicaid on the lab’s new CLIA status. This resulted in payments from all previously denied claims.
3) We worked with Blue Cross Blue Shield Medicare Advantage Plan to fully understand their coding guidelines and incorporated correct coding practices into the billing process. This resulted in the lab getting paid accurately on all previously denied claims.
4) We established a patient check collection protocol together with the lab, so that the patients were aware of any checks that would be sent to them and would promptly mail them to the lab upon receipt.

LIFE WITH NEXTSERVICES

The client enjoys the financial benefit of a methodical and rigorous billing process that continuously tracks problems and incorporates insurance feedback into daily operations.