A Laboratorian's Guide to Billing and Reimbursement for Molecular Microbiology Testing
This comprehensive review demystifies laboratory billing processes for molecular microbiology tests, covering insurance billing, procedure codes, health plan coverage determinations, and their downstream effects on test accessibility. The authors identify syndromic panels, antimicrobial resistance testing, and next-generation sequencing as key areas where laboratorians and manufacturers can improve reimbursement to expand adoption of evolving diagnostic technologies.
The original study
The laboratory billing process and its applications to molecular microbiology testing: guidance for laboratorians.
- Authors
- Starolis MW, Kapoor H, Jurcic Smith KL, Liesman RM, Zenefski DR
- Journal
- Journal of clinical microbiology
- Type
- Journal Article, Review
- PMID
- 40891849
Original abstract
The processes used by laboratories to seek reimbursement for services performed are complex and often unclear to laboratorians, a key group that has the clinical and technical knowledge to influence reimbursement. In this review, we provide a comprehensive overview of laboratory billing processes for insurance billing and hospital inpatient services, as well as the various procedure codes used in these processes. Understanding the health plan landscape is also of critical importance, as health plan policies and coverage decisions have downstream effects on accessibility of testing for patients. A detailed overview of health plans and how coverage determinations are made and communicated is discussed in this review. Lastly, we present actionable areas of opportunity in clinical microbiology where laboratorians, as well as test manufacturers, can focus on improving reimbursement (syndromic panels, antimicrobial resistance, and next-generation sequencing) to expand access to these evolving technologies and encourage adoption in clinical laboratories.