Thursday, June 16, 2022

Neogenomics Provides Insights Into Commercial Payers & Hospital Test Bundling

Note, on August 2, the main link of the original blog doesn't appear to be a live link at Neogenomics anymore.   

Neogenomics does have a webpage for "billing" and one for "third party billing" which have other useful resources.

Original blog follows.


Recently, on June 3, 2022, I published a blog about how the Medicare outpatient test bundling system works.   For example, CMS defines DNA-RNA MAAA tests as "molecular pathology" and unbundles them from a hospital outpatient visit.  But conventional tests (such as thyroid hormone or PSA) and non-DNA-RNA tests (like proteomic MAAA tests) are generally assigned a "Q4" modifier and bundled to the visit or procedure.  See June 3 blog here.  The rules were complexified during the Trump Administration, although basically in a way that made more tests separately billable.

One question clients always ask is, OK, Medicare bundles inpatient and outpatient tests under various (sometimes complexified) rules, what do commercial payers do?    

Neogenomics provides us some answers online.   Neogenomics is a large genomics laboratory, with a market cap approaching $1B and some $500M in 2021 revenue (here).

Neogenomics has a helpful claims processing overview on its website -

Neogenomics notes (fine print) it is an educational tool and each lab or party has to ascertain the correct rules that apply to it.

Basically, payors that follow the Medicare rules tend to be Med Adv plans, Humana, United Healthcare, and several BCBS plans for inpatient bundling.  (Other payers may except a test claim for the inpatient).   For hospital registered outpatients, molecular tests are billed straight to medicare (outside the bundle), while for many private payers, for their hospital outpatients, the molecular lab bills to the hospital, who presumably bills it onward to the payor.   For other private payers, they want to be billed directly for outpatient molecular testing, and NOT use the hospital as a middleman.   It's all on the slide at the PDF link above.


They also provide a PDF listing of payers that typically require prior auth for genomics: