By John (JD) Donnelly, Founder & CEO, FrontRunnerHC, including thoughts from 7 industry leaders
Originally published April 2023; updated November 2023
I believe “super-clean orders” have the power to transform healthcare. A super-clean order is a term we use in FrontRunnerHC to refer to orders that not only include accurate patient data but also ensure that ordered tests will be covered.
We were thrilled to have the opportunity for FrontRunnerHC to moderate three panels on the topic I’m so passionate about. And we were honored to have these seven healthcare leaders join us as panelists:
In Boston:
Rick Hood, Healthcare executive consultant with extensive experience in the healthcare and lab space
Mike Snyder, Executive VP, Network Solutions, Avalon Healthcare Solutions
Barry Wark, PhD, Co-Founder, Chief Strategy Officer, Ovation.io
In San Diego:
Matt Collins, CEO, MedLab2020
Ryan Hortin*, VP, Revenue Cycle, Myriad Genetics
In Chicago:
Nichole Kerr*, Senior Director of Revenue Services, Sonora Quest Laboratories
Steve Stonecypher, Founder and Partner, Shipwright Healthcare Group
We covered a lot of ground in these discussions, such as the value of super-clean orders, the challenges that stop clean orders from happening, and the collaboration required to consistently achieve them.
Though the panel discussions happened in three different places across the country with different panelists, each group came to a similar conclusion: having a super-clean order up front benefits everyone involved, including the lab, provider, payer, and patient. And regardless of the role in the lab order continuum, each panelist seemed excited and willing to work together to make super-clean orders the standard, rather than the exception.
While the panelists and the audience likely came away with their own key takeaways, I offer up five of my own below, along with just some of the many thoughtful comments from the panelists.
1. The silos that often exist between the various parties across the healthcare spectrum challenge the ability to achieve a super-clean order.
Ryan expressed that “a potential lack of alignment in their interests is part of the sticking point when it comes to defining a clean order. A patient, for example, wants to know their results are accurate; a payer wants to know the test is medically necessary.” He added, “Friction comes about as a result of the lack of information, and it impacts the lab, the provider, the patient, and even the payer.”
“We’re a bit of a disenfranchised industry with a sometimes-adversarial environment,” commented Rick. “Clients get mad at labs. Patients get mad at their physicians. All because the correct information isn’t being captured upfront.”
Matt referred to friction caused by integration challenges. “The patient intake systems that ordering providers use on the front often don’t match a lab’s data solution. That inconsistency can cause issues on the back end, especially when it comes to billing.”
2. The current process to get a super-clean order and comply with medical policy adherence and prior authorization is complex, broken, and burdensome.
Barry compared the healthcare ordering process to other industries. “The traditional workflow in healthcare doesn’t support the kind of feedback loops necessary to collect and revise information on an order once it comes into the LIS. Think about checking out an order on Amazon; they are sure to get the billing information right up front. In our industry, we put a lot of effort ensuring the clinical data coming in with the sample is correct but too little effort making sure the reimbursement and transactional information associated with that order is correct.”
Mike shared that “one of the biggest challenges is that labs don’t know what needs prior authorization until the order hits their lab.”
Ryan noted, “First, there is some variability in whether health plans require pre-authorization. Second, when they require it, oftentimes they want it submitted within two days of sample collection. So, the lab’s collection date of service can look inconsistent with the date of pre-authorization and that creates confusion.”
Steve shared, “I think the missing link is clarity and transparency. Without it, it’s really hard for a clinician to know what to order and what diagnosis code is needed. And how can we expect the lab to run those tests and not get paid for them?”
Nichole commented, “An ordering provider cannot possibly keep straight whether a test is covered or not for each patient’s unique insurance plan; so, anything that labs can do to try to ease that burden, including implementing medical necessity ask-at-order-entry questions, or presenting an Advance Written Notification regarding testing non-coverage, they should try to do, as it will ultimately provide a better result for everyone.” She also noted, “As a laboratory, the goal is to never perform unnecessary testing.”
I hear similar frustrations with the process when talking with medical groups. One physician told me he felt providers are often in the dark. “Which test do I order? What's going to be reimbursed through insurance? How much is the patient’s responsibility?” He wants to know that he is ordering the right test. And he wants to know in advance if he is ordering the wrong test and the claim is going to get rejected.
3. The current process negatively impacts all involved: labs, providers, payers, and patients.
Rick estimated that back-end denials can cost a lab 20-30% in claims and up to 60% of the staff spend time tracking down patient info. “It’s far more expensive and far more time consuming to collect the insurance and medical policy information at the back end, and in a lot of cases, there’s no chance in collecting at that point.”
But today as Barry shared, “It’s very hard for labs to implement a workflow with your providers that doesn’t ruin their day, your day, and the patient’s day.”
The patients certainly feel the pain too. The physician I mentioned above said, “We've got upset patients calling because lab tests aren’t covered.”
Rick and Ryan talked about the manual approach labs often take “to call the physician to get the right patient information.” It means “disrupting the physician’s busy day,” said Rick. And Ryan commented that “physicians may not remember the particular test or may already have their test result so they don’t necessarily have a strong interest in helping you. The provider can view your call as a pain.” In a similar vein, Barry noted, “Every time a lab has to go back to the ordering provider, it’s a burden on the provider. It’s one more reason they might go to a different lab in the future.”
Matt said his team sometimes searches for missing information by trying to reach out to patients directly via outbound phone and text, after working with providers to incorporate patient-consent language, but acknowledged that the approach has challenges, calling it a ‘quasi-solution’.
Mike may have surprised some when he said the current process causes pain for payers too. “The vast majority of payers want to pay claims efficiently. Remember that payers are a fiscal intermediary. They take in money for those members – such as a Medicare Advantage Plan or an employer group – so they are accountable for those dollars. They have to put administrative rules and tools in place. It is costly for payers to have to rerun or research claims and deal with appeals or reconsiderations.” He added that “appeals count against their Stars rating so a clean claim is actually an upside for the plan.”
4. Systemic change to consistently achieve super-clean orders is not easy but it is worth the effort.
Citing Conway’s Law, Barry acknowledged that systemic change is hard but possible. “In healthcare, we have silos that are not always aligned. But we have an amazing opportunity here.” He referenced “the ideas coming out of this panel discussion” and the “work being done to aggregate data and make a lot of these solutions possible.”
While Rick had previously shared the potential to increase reimbursements by reducing claims denials and enable staff to work on higher-value efforts with a super-clean order, Barry echoed the time savings. “The cost of fixing information at the back end versus fixing information at the front end is significant. For claims, information that comes in correct the first time takes labs less time.”
Most importantly, a super-clean order benefits patients, which is the number one priority for all of us. To paraphrase something I’ve heard Mike say before, patients will get the right test at the right time and will be charged the right amount.
The right test not only benefits the patient but our larger society as well. There is an opportunity to save billions by eliminating tests that have been ordered incorrectly.
5. The commitment to collaborate to address the problems that hinder a super-clean order is refreshing and energizing.
I have been in this industry for decades and can honestly say the conversations we are having and the collaborative efforts we are involved in with payers, providers, labs, and patients are unlike anything I’ve seen before. Together, we are driving change.
“A clean order means everything,” said Rick at the end of the panel discussion. “It’s critical for all of us to improve the relationship. It will help everyone involved. And labs want to cooperate.”
A common theme to fix the current process related to front-end transparency of all the required information and access to the appropriate data through an expanded use of technology upfront.
Mike added, “It’s not about us versus them. It’s about getting the right tools that are amenable to the workflow. Getting detailed patient information correct upfront is incredibly important. With all the labs out there and all the different payer plans, plan types, and requirements, labs connecting individually with each plan is not viable. We need transparency around the policies and upfront access to insurance eligibility information, including coordination of benefits. We need tools to help one another understand the required information and any changes to plan policies. I’m encouraged that there is a desire to come together to integrate and develop the solutions at the front end.”
I sincerely thank Barry, Matt, Mike, Nichole, Rick, Ryan, and Steve for joining us in these panel discussions. We genuinely appreciate their time and insights. Our involvement to moderate these sessions reflects our desire at FrontRunnerHC to collaborate with them and all the players across the industry to create a connected ecosystem leveraging innovative technology to consistently achieve super-clean orders that benefit everyone. It is time for change. We hope you’ll join us in the effort.
*Ryan Hortin mentioned at the start of the panel that his comments are not necessarily attributable to his employer but represent his own 15 years’ experience in the industry. Similarly, the comments shared by panelist Nichole Kerr are not attributable to her employer Sonora Quest Laboratories but rather, represent Nichole’s personal views from her 15 + years of experience in the laboratory industry.