Update: Prepayment Laboratory Claim Edits implementation

In a July Record article, we wrote about the proposed implementation of a laboratory benefits management program through Avalon Healthcare Solutions and asked for input from our facilities. Based on that input, we’re providing some additional information about the program below:

• Blue Cross Blue Shield of Michigan will continue to share the science, policies and policy summaries to assist in the development of “test menus,” the order forms sent to health care providers with a list of tests.
• Educational sessions have been provided since June and will continued to be scheduled throughout the year. These sessions are intended to educate providers on Blue Cross’ Lab Benefit Management program and polices.
• The Office of Inspector General believes laboratories have a duty to modify their practices, as well as notifying physicians or other authorized individuals of their concerns and recommending corrective action to aid in ensuring appropriate ordering and execution.
• Inappropriate ordering of labs can be addressed through understanding and adherence to Blue Cross policies as outlined through coverage criteria and diagnosis codes. 
• Blue Cross has taken all lab policies through our review process, including several facility representatives who supported the adoption of these new policies. Any future enhancement and adjustments to Blue Cross lab policies will also be fully vetted before assimilation into practice.
• Claims can be appealed through the standard clinical editing process. Medical records from the ordering physician must be included with the appeal.

Following Blue Cross’ review of facility input, we’ll be moving forward with this program in early October. Details about the lab benefits management program were also presented at the Aug. 24, 2022, Staff Liaison Group meeting, which included leadership from the Michigan Health and Hospital Association and Blue Cross, and at the Sept. 29, 2022, PHA Advisory Committee meeting.

Avalon is an independent company that contracts with Blue Cross to provide laboratory benefits management.