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Overcome the Challenges of Adapting to Noninvasive Prenatal Testing (NIPT) Requirements

Claim submission requirements change by the minute and by payer, and most laboratories do not see this happening until it’s too late. By the time denied claims are noticed it’s already negatively impacted your revenue.

Unfortunately, the genetic laboratories bringing innovative solutions to the market, such as Noninvasive Prenatal Testing (NIPT), and other lifesaving screenings, are the ones dealing with the most volatility surrounding reimbursement policies.

For example, in 2019 insurance payers changed the way they reimburse NIPT tests without any prior notice to providers. Payers had determined too many patients were using NIPT for non-clinical procedures such as finding out the fetal sex of the baby. New qualification requirements were added to prioritize high risk pregnancies including patients who are 35 or older at the time of their due date, patients with pre-existing medical conditions, and patients with a family history of medical conditions. This shift caused a rift in claims that came back denied.

The problem is that many providers and in turn, patients are left to pay for a large, uncovered bill.

How do you limit the financial exposure of payer reimbursement changes?

First, keep in mind that any efforts to balance economic motivations must be done while remaining compliant. Non-compliance equals non payment.

From there make sure your processes and tools are aligned to detect reimbursement changes early. The earlier a change is caught, the lower the exposure to financial risk.

Here’s some ideas:

  1. Build a system capable of pre adjudicating an ideal payer outcome. If the payer outcome is bad, triage the issues in a way that is patient and provider friendly. For example, if a test were not compliant, a laboratory could have an automated way to reach out to the provider to ask for additional clinical information.
  2. Make sure the requisition forms reflect the fields needed to capture relevant clinical data and support the test. Stay up to date with requirements and design the requisition form to acquire the right information.
  3. Be prepared for an appeal. In the case that your claim is denied, build your system so that it aggregates all of the clinical information needed to have a successful appeal.
  4. Make the information easy to consume. When you acquire the clinical information, make it so it's not discreet. Show the information on a sheet so it’s clear what’s there.
  5. Identify a patient's risk on the front end, preferably before an order is placed. In other words, give providers a calculator or a tool to use which can quickly identify whether or not testing is appropriate based on the patient's criteria.
  6. Implement a digital way to intake orders. An electronic order on the front end gives laboratories several days before the receipt of a sample to prioritize this process, without negatively impacting the turnaround time of the test.
  7. Predictive healthcare data analytics helps identify trends. This visibility reveals the payers who are not following their own medical policies, and catches errors on your end.

These solutions are recommendations to help laboratory leaders gain oversight of NIPT claims. By adding steps to verify successful processing upfront and before submission, you can streamline your efforts with any changing NIPT testing requirements. An optimized system verifies patient qualification for testing while checking to make sure all parties involved are working on a schedule to get claims processed on time and effectively. Though there is some work up front, these steps help to plan ahead and avoid future negative impact on your revenue.

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