Overview

The client is an independent medical laboratory located in the Southeast of the U.S. that has served its local community for almost seven years. It is a full-service lab including blood culture, toxicology, and molecular testing.

• RELATED CASE STUDY: Expanding Molecular PCR Services by Securing Nationwide Payer Contracts

 

The Lab’s Challenges and Objectives

The lab in question first reached out to us in 2021 to receive guidance on responding to payer concerns about possible coding errors. At this initial stage, the Lighthouse RCM Solutions team was tasked with analyzing the coding and providing general RCM consultation.

However, as this client has grown to meet the needs of the industry, our expertise and team have grown with them. Our team now aids in every aspect of the revenue cycle development and management, including the use of our AI-powered RCM Spotlight tool to monitor and analyze the payer mix. Through our consistent analysis of denials, we determined there was ample opportunity to enroll with new payers and expand their overall footprint with new contracts.

The top 5 payers based on utilization for this lab:

• BCBS
• Medicaid
• Medicare
• United Healthcare
• Humana

As most independent labs know, obtaining In-Network status can be a difficult and burdensome process. Given this concern, we brought in our dedicated Payer Strategy consultants to help obtain a contract with the Contigo and Direct Pay rental networks. These two networks offer Out-of-Network coverage that can result in 120% of Medicare, with hundreds of payers falling under their umbrellas. Additionally, Aetna, Cigna, Humana, and UnitedHealthcare are all in the Top 20 of this lab’s payer mix and fall on the list of covered payers, making these great contracts to pursue.

We then reviewed other contracting opportunities to help our client recognize the benefit of pursuing the full assortment of Blue Cross Blue Shield and Molina Healthcare contracts across the nation as they continue to expand their business model.

 

Solutions

After identifying the contracts we would target on behalf of our client lab, our Payer Strategy team utilized their extensive payer connections to speed up the timeline of obtaining contracts and open opportunities in narrow or otherwise closed networks. To help the client’s chance of success and make them more appealing overall to these payers, their test offerings were presented in a compelling application. From start to finish, we were able to expand our client’s footprint by obtaining seven major contracts in under four months.

“From the start of the contracting relationship, the client and the RCM/Payer Strategy Solutions teams met in collaborative sessions to ensure the contracting strategy was appropriate and achievable,” says Brian Burns, Vice President of Payer Strategy at Lighthouse.

Results

Five Blue Cross Blue Shield contracts have already been obtained:

• Blue Cross Blue Shield of Arizona
• Blue Cross Blue Shield of Illinois
• Blue Cross Blue Shield of Kansas
• Blue Cross Blue Shield of Texas
• Blue Cross Blue Shield of Michigan

These five BCBS plans account for more than 30 million lives covered, which provides a substantial sales and revenue opportunity in the market.

Two Out-of-Network rental contracts have been obtained:

• Direct Pay/Three Rivers Provider Network
• Contigo Health

These rental network contracts can provide out-of-network coverage and reimbursement for Aetna, Cigna, Humana, UHC, and hundreds of other small payers nationwide. These contracts have the potential to provide excellent reimbursement up to as much as 120% of Medicare for payers that otherwise make laboratory reimbursement very difficult and inconsistent.

We are continuing to pursue 6 other contracts, which are in various stages of the process:

• Blue Cross Blue Shield Carefirst (Washington DC, Maryland, Northern Virginia)
• Blue Cross Blue Shield of Kansas City
• Blue Cross Blue Shield of Louisiana
• Blue Cross Blue Shield of Tennessee
• Blue Cross Blue Shield Wellmark (Iowa and South Dakota)
• Molina Healthcare of Illinois

Dyana Williams, Client Engagement Manager for Lighthouse, says this case is a perfect encapsulation of the benefits of working to improve your billing and payer approach in concert.

“This is a perfect example of the internal collaboration and support that Lighthouse provides for their clients,” says Williams. “Our teams work together to identify client needs and identify opportunities – all to improve client success.”

 

Client Feedback

“We previously had engaged Lighthouse on an ad hoc basis but switched to RCM consulting based on positive experiences and the desire for a continuing and sustaining consultation. Lighthouse staff have been very valuable and have more than justified the consulting fee. They interact with us and our coding/billing team in a responsive, personable, and collaborative manner. They quickly and expertly respond to emails and calls and are very customer oriented.

Based on that experience, we added credentialing services to the engagement. It has proven to be productive, and of good value to us.

Lighthouse has wide industry and sector knowledge and experience. Our relationship with Lighthouse has proven very positive.” – Feedback provided by the lab’s General Counsel

 

Ready to Improve Your RCM Health and Payer Contracting Strategy?

If you’re looking for a partner to assist with payer contracting, credentialing, or examining your overall RCM health, don’t hesitate to contact us for a free consultation. We would be happy to share more success stories to provide you with a better understanding of our capabilities and expertise.

 

About Lighthouse Lab Services

Lighthouse Lab Services is a medical lab consulting and management firm that offers end-to-end technical and business services to laboratories across the country. Founded in 2003 as a lab recruiting firm, the company has expanded throughout the past 21 years to offer lab startup and management services, validations, instrument service and preventative maintenance, and more. The company also boasts a deep bench of RCM and payer strategy experts who specialize in the lab and pathology industries. Lighthouse is headquartered in Charlotte, NC, learn more at lighthouselabservices.com

 

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