Nov. 4, 2022

BCBSIL Enters Value-Driven Agreement for Outpatient Lab Testing
Applies to fully insured groups, non-HMO

Effective Nov. 1, 2022, Blue Cross and Blue Shield of Illinois (BCBSIL) implemented its Laboratory Benefits Management (LBM) program with Avalon Healthcare Solutions for certain outpatient laboratory services provided to many of our commercial insured, non-HMO members. Avalon’s programs have served health plans since 2016, operating in 15 states with more than 45 million insureds.

Some of the goals of the LBM program are to reduce wasteful testing, lower cost variability and promote high quality care for our members. The LBM program supports a value-driven approach to outpatient laboratory testing as part of our commitment to provide affordable health insurance premiums for our members.

The LBM program applies to commercial outpatient laboratory claims (typically performed in an office, hospital outpatient, or independent laboratory setting) with dates of service beginning Nov. 1. Laboratory services provided in an emergency room, hospital observation or hospital inpatient setting are excluded from this program. Member coverage terms still apply. Additionally, claim edits will not initially apply to the rate at which tests have been ordered or with respect to the age or gender of a patient.

Provider agreements with BCBSIL provide the terms and conditions that might allow a provider to seek reimbursement for laboratory and other procedures beyond a member’s cost share. Whether in-network or out-of-network, a provider may need permission from a member to bill that member for any non-covered services. For that reason, providers should understand and implement the Clinical Payment and Coding Policies criteria rather than seek reimbursement from their patient or request a waiver for payment. It is BCBSIL’s position that no payer, including employers, and no member, should be forced to compensate any provider for a test that is wasteful.