Guidance for Brokers and Employers
The following testing options, pricing, and logistics solutions provide guidance for employer groups wanting to test employees for Coronavirus Disease (COVID-19) when returning to work.
Virus Testing Approach 1 – Minimize Insurance Plan Billing
Private Insurance plans provided by employer organizations, and plans that employees might have elsewhere, are all required to pay for COVID-19 testing with NO-COPAY. This includes Out of Network doctor visits. The most common testing methods with billable codes are nasopharyngeal and oral swab sample collections which are sent to labs for testing using existing CPT and ICD testing codes, according to CMS and AMA guidance. With proper billing, the total billed cost per employee for COVID-19 testing should be $102.66, where $51.33 is billed by the doctor, and
$51.33 (UPDATE $100) is billed by the Lab. The total COVID-19 test cost per employee billed to the plan should be $102.66 ($152). UPDATE ON APRIL 15TH CMS INCREASED THE REIMBURSEMENT FOR LABS FOR CERTAIN TESTS FROM $51.33 TO $100 MAKING THE TOTAL PLAN COST FOR THIS NOW $151.33 PER PERSON.
Unfortunately, what we are witnessing in the marketplace are the same overbilling practices we see all the time. Health systems and labs work together to bill full respiratory panels at $231 which includes the COVID-19 testing, plus additional unwanted testing when all that is desired by employers is the COVID-19 test for return to work. The medical justifiable reason being that patients might have the regular flu, bronchitis, or other viruses, so they must test for all. You may have even seen news clips of hospitals testing for both at their drive through centers.
Cost Comparison Example: Assume testing of 10,000 employees.
- Best case scenario: 10,000 x $102.66 = $1,026,600 – ADD ADDITIONAL $500,000 for highly complex lab classification PCR tests $1,526,600
- Overbilling scenario: 10,000 x $231 = $2,310,000. This is a 125% or 2.25 times overbilling scenario. Reduced by $500,000
- Potential for $1.284 Million in billed cost savings. Reduced by $500,000
Recommendation: Partner with local practices or healthcare systems to control your costs. Employers and employees should insist on COVID-19 only testing and billing.
Virus Testing Approach 2 – Lab Billing with Provider Flat Fees
There is no way to circumvent the DNA PCR lab analysis machines that heat and cool the test swabs to get positive or negative test results. With this option an employer group uses the labs, but contracts directly with doctors or healthcare systems and brings them onsite for a flat fee. The practice or healthcare system performs all testing and swabbing for one flat fee which eliminates all doctor billing for each test.
The primary argument against mass swab/PCR testing is that you are now putting an unnecessary burden on the labs by testing people that were not showing symptoms and were never exposed. Therefore, results are delayed for those individuals that are positive and might not be quarantining as soon as they should. For example, test results coming back in 5-7 days instead of 2-3 days due to the increased lab burden.
While once a sample arrives at the lab, much less can go wrong with the testing procedure, keep in mind that there are still many possible points of failure in the end-to-end process. Some doctors will also argue that several things can go wrong with lab testing due to human or technological procedural errors which can lead to false negatives or no reading at all. Some examples cited include the following:
- Medical providers might not obtain testable (good enough) samples
- Lab bags can be mislabeled
- Improper storage of samples prior to shipment to labs
- Shipping issues causing problems if not delivered on time or in a prescribed manner
- Sample mishandling by lab technicians
- Technical or human errors with lab machines leading to incorrect results
- Time delays and inefficiencies in result notifications by labs
Cost Comparison: Assume testing of 10,000 employees.
- Lab cost – Employer group still incurs $513,300 in lab costs (10,000 x $51.33 per employee) $1,000,000 in some cases after the APril 15th update (potentially now $100 per employee)
- Doctor flat fee cost – A fair flat rate price with doctors taking on the staffing liability and supply purchasing with proficient logistics planning would be about $250,000 for a 7 to 10-day testing event. The Doctor is taking a 50% pay cut, but they are being guaranteed the volume for all employees.
- Total – $763,300 to the plan ($513,300 + $250,000) +$500,000 depending on test used April 15th update
Recommendation: Partner with local practices for agreement on flat fee billing for doctor services. The only service billed to the plan would be the lab charges.
Approach 3 – Rapid Panel Antibody Testing
Rapid Panel Antibody testing is a way to determine if individuals have already made antibodies to the virus. The general medical assumption is that those individuals with these antibodies should be resistant to becoming symptomatic with further exposure to COVID-19, and that they will no longer spread the virus to others. Keep in mind that Rapid Panel Antibody testing is very different from lab-based nasopharyngeal and oral swab testing in purpose, method, and procedure. It is important to note that though Rapid panel testing is currently approved in other countries and has been in use there for weeks/months in some cases they are not FDA approved currently in the USA. The only rapid panel approval at this time has EUA (emergency use authority approval) What that means is that a carrier most likely will NOT reimburse for the test so an employer would need to self pay/cash pay for services and the tests. Which many companies across the united states have already started doing.
These Rapid Panel tests use a finger prick blood sample to determine if your body has made antibodies to the COVID-19 virus, and the results are usually available within ten to fifteen minutes. These tests have EUA FDA authority for clinician use, but they are NOT considered as accurate as the lab-based Swab/PCR testing that is used to determine if individuals currently have the COVID-19 virus. Current clinical testing shows that Rapid Panel tests are 95% to 97% as accurate as the lab Swab/PCR test which are the most accurate with no human error.
Rapid Panel Antibody tests are starting to flood the market with different branding, different providers, and so on. Provider/doctor purchase pricing for these tests have been ranging $4 to $79. It is indeed the wild west and if it sounds to good to be true, it is. What you pay to import from China may never show up in time or at all. Doctors do not currently have a NO-COPAY CPT code they can bill which is why this is basically a direct pay business to doctor transaction.
Different types of Rapid Panel antibody tests are being developed. Some tests show that you had the virus, recovered, have a needed antibody level, and should not be able to spread to others. Some tests identify if you are still in the middle of an infection, while other tests use machines to give a near exact timeline for when the virus was contracted based on the body’s antibody response. Regardless of the type of test, Rapid Panel antibody testing can be a significant cost avoidance approach for health plans that can be strategically implemented with approaches 1 and 2 above to significantly reduce the amount that labs and doctors bill to health plans.
There are 3 basic scenarios with this type of testing:
- An individual has contracted the virus, recovered, and their body has created antibodies. In this scenario the individual tests positive for antibodies at a level that is presumed that they can return to work and not shed the virus to others.
- An individual has begun to create antibodies, but not at a level that shows recovery from the virus. The CDC recommendation is to conduct Swab/PCR testing for secondary confirmation that the individual has the virus and immediately self-quarantine for 14 days.
- An individual shows no creation of antibodies. In this scenario there are 3
- The individual has not contracted the COVID-19 virus.
- The individual has contracted the COVID-19 virus, but they are too early in the development of the virus in their body to show a positive antibody test.
- The test failed- test again is recommended.
In these 3 scenarios there are no CDC recommendations however it is recommended if an employer group wants the test run to default back to a PCR nasal swab test.
Cost: Assume testing of 10,000 employees. Antibody testing would range from $475,000- $600,000 depending on the practice/doctor purchasing and logistics cost and number of secondary confirmation swabs that would be billed out from lab.
BLOOD DRAW ANTIBODY-
The most accurate form of antibody testing currently is intravenous blood draw which is a $50 plan reimbursement (or cash pay) to the labs as well as a nurse visit code / doctors order of the test and collection of sample typically $45 cash pay or between $45-$55 depending on age of the client when reimbursed by plan.
Recommendation: With COVID-19, some current research and data suggests that up to 80% of individuals who have contracted the virus are asymptomatic or show very minor symptoms and recover. Rapid Panel Antibody testing can be used as less expensive 1st line testing option to determine who these individuals are with the presumption that they can return to work without spreading the virus or contracting it again (reinfection rates are unknown at this time). And you won’t find a doctor on the planet that says you are 100% immune once you have had it once, it is all too early to tell.
There are many testing options, pricing plans, and logistics solutions for employer groups wanting to test employees for Coronavirus Disease (COVID-19) when returning to work. With potential for 50 to 90 percent cost savings from overbilling scenarios, the three approaches outlined in this document will help employer groups control their costs as we transition back to work.
While each approach provides benefits, strategies that utilize Approach 3 alone or in concert with other options should be included as a most logical option for any mid-market or large employer that wants to test employees before returning to work.
To execute testing options in a most cost effective and beneficial manner, employers should demand safe, onsite, popup testing clinics. While this can be accomplished in many ways, WalkOnClinic™ is partial to using the outdoor drive through model, combined with a mobile healthcare unit. It is recommended that you partner and work with companies with experience handling onsite testing, logistics and large-scale community and private testing.
For more questions regarding how to make this happen for an employer group you know contact email@example.com