How to fix Lab test denials: Part 1 - Expert Advice from the Medical Billing Whisperer

By Martine G. Brousse

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro

January 3, 2024

Watch the video: https://youtu.be/c2HBFaRLjI8

There are a number of reasons why your insurance plan would reject payment of a lab test.

Today we will see how to fix the most common reason: THINGS DON’T MATCH THAT SHOULD!

A. Coding errors

1. Coding and Billing protocols are simple: any medical procedure/service/lab/test/supply/item/intervention/care/Rx/consultation/device MUST have a specific, documented, justifiable medical reason to be ordered.

2. That medical reason is the “diagnosis”

3. A lab test is ordered with the corresponding diagnosis code by the prescribing physician and those codes are then used by the laboratory provider to bill your insurance

4. Any mismatch, or incongruity will result in a lab test being rejected as “not medically necessary” or even “experimental”.

5. Examples:

· "Female Breast cancer" code linked to a PSA test in a male cancer patient (they exist!).

· A thyroid function test ordered for anemia

· A CA-125 (ovarian cancer detection test) ordered for primary brain tumor

B. Demographic errors

1. These are the “stupid” mistakes such as wrong patient age, sex, insurance ID#, etc

2. If the info on the claim does not match the info in the insurance system, the claim will be rejected as “not eligible”

3. If the info on the claim does not match the lab test code, then the denial will likely be “experimental” or “not medically necessary”

4. Examples:

· A pregnancy panel for a 55-year old patient. Patient is actually 35, but the year of birth was inputed incorrectly.

· Newborn’s blood panel billed under his older toddler sister’s name. Wrong patient.

C. Coding Fixes

1. This one is easy: the prescribing Dr must send an updated order with the correct code to the lab provider. The lab then resubmits the claim to the insurance as “corrected claim” and gets paid.

2. Don’t waste your time telling the lab provider to correct this mistake, as they do not have the authority to do so and must rely on the referring provider’s updated order to make any change.

D. Demographics fixes

1. Even easier: correct the system with the proper data, and resubmit the claim as new.

E. There are un-winnable cases

1. Some lab tests, unfortunately, are so unusual or uncommon that they may be restricted to a specific rare disease, condition or segment of the population.

In such cases, strict adherence to the established protocol must be followed to get paid.

2. Example: a in-utero test to rule out a genetic disease is performed on a woman who wants to know whether she is a carrier before getting pregnant. Because the test only is covered during pregnancy to screen her fetus, her claim will be denied, with no way potential documentation or medical justification to appeal.

For more info on lab tests and what they mean to your bottom line: https://www.advimedpro.com/post/billing-codes-basics

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.