An analysis of billing errors within the medical laboratory industry reveals a critical vulnerability: approximately 25% of all claim denials originate during the initial specimen intake and accessioning process. Unlike standard medical practices, laboratories often receive patient data indirectly via requisitions from referring providers, increasing the risk of "garbage in, garbage out" scenarios. These pre-submission errors ranging from missing diagnosis codes to outdated insurance information cost laboratories thousands in rework and write-offs. To combat this, a three-pronged strategy is presented, focused on reinforcing the accessioning workflow. The core solutions involve mandating automated eligibility verification for every specimen, implementing rigorous validation of test requisition forms (TRFs), and utilizing a standardized intake checklist to ensure procedural consistency. Adopting these foundational practices can stop denials at the source, leading to faster and more reliable reimbursements.
The central argument posits that a significant portion of laboratory claim rejections can be traced back to the point of origin: accessioning. It is asserted that a quarter of claim denials start before the test is even performed or the claim generated.
In a laboratory setting, the "front desk" is actually the intake department. The source of the problem is rarely the sophisticated laboratory information system (LIS) or the billing team, but rather a breakdown in the fundamental task of capturing data from the ordering provider’s manifest or requisition form. Errors made during this initial phase cascade through the revenue cycle, leading to denials that are difficult to overturn once the specimen has been processed.
To address these intake failures, the following three actionable strategies are outlined to stop rejections before they reach the clearinghouse.
The first and most critical step is to verify insurance eligibility for every single specimen received, with no exceptions. Because the lab often does not interact with the patient directly, this process must be automated and rigorous.
Methods: Implement batch eligibility tools integrated into the LIS that run checks the moment a specimen is accessioned.
Verification Points: The key elements to confirm during this process are:
Active Coverage: Is the policy active on the date of service (date of collection), not just the date of receipt?
Benefit Specifics: Does the patient have coverage specifically for laboratory services (CPT range 80000-89999)?
Payer Match: Does the insurance card image or payer ID on the requisition match the electronic eligibility return?
Ensuring the integrity of patient demographic and insurance information is paramount. In a lab, this requires validating the data provided by the referring physician against the actual insurance records.
The "Requisition vs. Reality" Check: Accessioning staff must verify that the information on the Test Requisition Form (TRF) matches the electronic order or insurance database. Common points of failure include mismatched spellings of names (e.g., "Bob" vs. "Robert") or transposed dates of birth.
Standardize Data Capture:
Electronic Ordering: Encourage referring providers to use EMR interfaces (HL7) rather than paper requisitions to reduce handwriting errors.
Mandatory Fields: Configure the LIS to prevent the "release" of an accession number unless critical fields (Zip code format, subscriber ID format) are satisfied.
Pre-Processing Review: A crucial step is to "hold" non-STAT specimens that have incomplete data. If a diagnosis code (ICD-10) is missing or invalid for the ordered test (medical necessity), the sample should be flagged for client services to contact the ordering provider before the test is run and billed.
To ensure that no critical steps are missed during high-volume intake periods, a specialized checklist for accessioning technicians is recommended.
Purpose: A standardized workflow ensures that complex tests (like molecular or genetic panels) meet specific payer criteria before resources are wasted on testing.
Oversight: A laboratory supervisor should perform random audits on accessioned batches to ensure the checklist is being utilized.
Essential Checklist Items:
Demographic Confirmation: Verify the patient’s name, DOB, and address match the insurance eligibility response exactly.
Ordering Provider Validation: Confirm the ordering physician’s NPI is valid and that they are authorized to order tests for this patient type.
Medical Necessity (LCD/NCD) Check: Verify that the provided ICD-10 codes support the medical necessity of the specific CPT codes ordered (checking Local and National Coverage Determinations).
Prior Authorization: For high-cost tests (e.g., genetic sequencing), confirm an authorization number is present and valid.
Advance Beneficiary Notice (ABN): If medical necessity criteria are not met, confirm a signed ABN is attached to the requisition to bill the patient directly.
By focusing on these three foundational areas: automated eligibility, requisition data integrity, and accessioning checklists laboratories can proactively eliminate the source of nearly a quarter of all claim billing errors.