By: Tami Shaw, Client Manager, Lighthouse Lab Services/Vachette
While it’s great to see the world of clinical lab testing has grown and innovated in response to the COVID-19 pandemic, the reimbursement side has been slow to keep pace with these changes. As a result, nearly every insurance payer now has a policy in place to prevent reimbursement for testing any more than three to five targets. While CPT code 87631 is acceptable to most, CPT 87632 and 87633 are denied as not being medically necessary simply because they are testing more than five targets.
Although we have great coverage options like the Health Resources and Services Administration (HRSA) Uninsured Program, which enables providers to get reimbursement for COVID-19 testing for patients who have no insurance, that coverage is not extended to large respiratory panels. From a payer perspective, it is seen as throwing a dart at a dartboard simply to see what you come back with. While many of us are quick to argue that such panels can get us to the correct answers quicker, it is still seen as not medically necessary.
Payers have undertaken an initiative to restrict policies to intentional, focused care. The testing of these extra targets is seen as unnecessary bling at a fashion show. They demand fashion with less gaudy baubles, in favor of a more minimalistic, customized fashion, so to speak. Minimal testing is the new black (in a payer’s eyes).
Utilizing the HRSA Uninsured Program
In terms of federal reimbursement, it’s important to note the HRSA Uninsured Program does not pay for CPT codes 87631, 87632, and 87633. Again, claims for qualifying services can only be submitted for reimbursement when the patient has no insurance coverage.
HRSA does pay for more than just COVID-19 testing, though. They will also pay for the COVID-19 and Influenza A/B combination, as well as the combination of COVID-19, Flu A/B, and RSV. The logic here is that these three respiratory issues are very common and have such similar symptoms that they can often be misdiagnosed without testing for them. The efficiency of testing them in combination has shown to save on supplies and resources, which allows for testing a larger volume of the population and gets patients out of clinics faster.
In summary, HRSA will not only pay for straight COVID-19 testing; but also:
- 87636 (Covid+Flu)
- 87637 (Covid+Flu+RSV)
As the pandemic continues to evolve, it will be quite interesting to see how this next year changes the industry even more. It’s hard to say how long programs like HRSA will continue to be around once the Public Health Emergency expires. But for now, it’s a great benefit to providers offering these crucial services that we have these reimbursement options in place.