Overcoming Hurdles to Medical Lab Reimbursement: From MolDx to Medical Necessity

Reimbursement remains one of the most persistent and complex challenges facing clinical laboratories today. From medical documentation requests and denied claims to patient billing challenges, structural obstacles across the healthcare landscape continue to limit labs’ ability to get paid for medically necessary testing.

Chief among these persistent issues are the reimbursement roadblocks faced by labs performing PCR-based testing in MolDx jurisdictions. The lack of approved clinical studies has left labs unable to obtain the Z-Codes necessary for reimbursement. However, Lighthouse has identified a viable path forward, and we’re seeking labs and stakeholders interested in joining forces to pursue a clinical study capable of gaining Z-Code approval.

We recently gathered a panel of revenue experts to address these issues in addition to broader reimbursement challenges that continue to impact labs across the country. Joined by leadership from Cellarian and Inbox Health, we covered:

✅ Strategies for reducing administrative burden and avoiding denials through smarter clinical documentation workflows and automated solutions.

✅ A look at why PCR UTI testing continues to face stiff headwinds in MolDx jurisdictions due to a lack of clinical utility studies.

✅ A proposed path forward for achieving Z-Code approval and how your lab can get involved in a collaborative clinical study effort.

✅ Practical insights into improving the patient billing experience to ensure you're maximizing collections.

Whether you're dealing with documentation requests, reimbursement delays, or struggling to get paid at all, this session offers actionable insight into how labs can compliantly increase revenue while forging new reimbursement pathways for the vital services they provide.

Jump to:

-Overview of MolDx (4:09)
-Potential path forward for PCR studies (5:05)
-How medical necessity ties into MolDx reimbursement (8:47)
-Why Z-Codes and Technical Assessments don't equal payment (10:30)
-Importance of medical necessity (12:10)
-Solutions for compliantly automating document requests (16:47)
-Why coverage means payment (18:33)
-Exploring patient billing solutions (22:40)
-Q&A (44:50)

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