Friday, September 20, 2019

Businesses Aim to "Manage" Lab Orders & Reimbursement; House Hearings on Prior Authorization

For several years, Dark Report has published regular articles on the growth of the "Lab Benefit Management" or LBM industry.  Panels on this topic are a regular part of lab industry conferences.  Notably, in August 2019 investor call, Myriad noted that in recent quarters it had lost $50M due to LBM edits (primarily on CYP CPT codes; see also here.)

Currently, in September 2019, see a deep-dive article on test order management as a growth industry in themselves, by Adam Bonislawski at 360Dx.  Article here.  (360Dx is a sister journal to Genomeweb).


There's also a must-read article on similar topics by Anne Paxton at CAP TODAY; September 2019, here.  However, the next section pivots from Bonislawski's article at 360Dx.


CONTROLLING AND GUIDING PHYSICIAN TEST ORDERS

Rather than focusing on traditional LBMs, which help payers institute prior authorization, claims editing, and denials, these new companies focus on EHR-based software that review and redirect test orders right during the physician's initial ordering process.  Players include NDSC for its CareSelect Lab, and Medical Database Inc's Lab Decision System or LDS.  See a new open-access publication on the value of LDS by Leblow et al. here.  (Leblow et al. also has an up to date bibliography on hospital efforts to reduce lab overuse). 

The 360Dx article also highlights a JAMA article using machine learning to cull low-value lab tests (Xu 2019, here), and discusses the Quest Lab Stewardship programs (here, here), which partner with vendor and AI company "hc1" (here).

The lab management industry also builds on platforms developed for radiology medical necessity management (see the "AUC" or "Appropriate Use Criteria," required in the last couple years by CMS.  This was created by PAMA 2014, the same omnibus Medicare adjustments law that created today's lab pricing rules.)


PRIOR AUTHORIZATION: BURDEN: CONGRESS


Only Here: 
Collection of Links - and a House Hearing - 
on Prior Authorization 2018/2019


In a separate "Notepad Blog," I've collected about 20 links.  Not specific to the lab industry, I've collated OIG reports, letters to Congress, the AMA Prior Auth Website, and trade journal articles on abusive prior authorization processes.

I've also provided a ZIP file that collates all the documents from a House Small Business Committee hearing this week, including a full-length transcript of that hearing which describes four viewpoints on the high burdens placed on providers by prior auth systems.

See these links here.

Healthcare Dive article; providers loathe prior auth; here.  Based on survey from Medical Group Management Association - here.
___

Actual "word cloud" of Adam Bonislawski article:


https://www.wordclouds.com/