5 Effective Payor Negotiation & Market Access Strategies for MRD Testing

Minimal Residual Disease (MRD) testing is at the forefront of personalized oncology, offering precise monitoring of treatment effectiveness and early relapse detection. However, despite its clinical importance, MRD testing faces significant challenges in reimbursement, payor contracting and coverage negotiations, and market access due to complex coding, inconsistent payor policies, and frequent denials.

This article explores five effective strategies for payor negotiations and market access for MRD testing, empowering laboratories and healthcare organizations to secure better coverage and maximize reimbursement.

1. Strategic Use of Coding: Choosing Between 81479 and PLA Code

One of the primary challenges in MRD testing reimbursement lies in selecting the appropriate coding method. Two main coding options are available:

• 81479 (Miscellaneous Code): This code is broad and nonspecific, leading to high denial rates and inconsistent payments due to insufficient description. Since payors often struggle to determine the exact test performed, they frequently request additional documentation, adding administrative burden and delaying payment.
• Proprietary Laboratory Analysis (PLA) Code: PLA codes are more precise, test-specific, and proprietary to the lab or manufacturer. They provide better traceability and are recognized by payors, allowing for more consistent pricing once negotiated.

Coding Strategy Tips:

• Choose Wisely Based on Payor Policies: Evaluate payor requirements and preferences before deciding on a code. While PLA codes are more specific, commercial payors often vary in their acceptance. Many require Z-Codes for both 81479 and PLA codes, while some have proprietary coverage policies that treat PLA codes differently. Be sure to check each payor’s requirements.
• Be Aware of Denials and Documentation Requirements: While PLA codes generally result in fewer denials, they are not immune. Both codes require accurate test descriptions and meticulous documentation to support medical necessity.
• Negotiate Transparent Pricing: PLA codes allow for more predictable reimbursement and can be leveraged during negotiations to secure consistent pricing.

Engage with payors early to understand their coding preferences and negotiate coverage terms that accommodate the complexities of MRD testing.

2. Bundle Payment Negotiations: Streamline Multi-Test Series

MRD testing typically involves a series of tests throughout a patient’s treatment cycle. Negotiating a bundled payment rate for the entire series of MRD tests can provide financial predictability and minimize per-test denials.

Why Bundle Payments?

• MRD testing follows a specific sequence, including post-treatment, pre- and post-stem cell transplant, and ongoing monitoring. Payors are more likely to agree to bundled payments if the intervals and frequency of tests are clearly defined in the contract.
• Bundled payments simplify revenue forecasting, allowing finance teams to plan for consistent revenue over the patient’s treatment cycle.

Best Practices for Bundled Payment Negotiations:

• Clearly Define Testing Intervals: Specify in the contract when each test will be conducted (e.g., post-treatment, every six months) to avoid ambiguity.
• Align with Clinical Guidelines: Use established clinical guidelines (e.g., from ASCO or NCCN) to support the necessity and frequency of tests included in the bundle.
• Educate Payors: Demonstrate the cost-effectiveness of bundled payments by showcasing the clinical value and improved patient outcomes of MRD testing.

Bundle payments can reduce administrative burden and improve cash flow stability, making them an attractive option for both payors and providers.

3. Leveraging Analytics for Market Access & Payor Negotiation

Effective payor negotiations are data-driven. By leveraging Business Intelligence (BI) Reports and Data Analytics, laboratories can gain insights into payor behavior, denial patterns, and reimbursement trends, which are crucial for strategic negotiation.

Data-Driven Market Access Tactics:

• Monitor Claim Denials & Appeals: BI reports can identify the top reasons for denials, helping labs prepare evidence-based appeals and adjust documentation practices accordingly.
• Analyze Reimbursement Trends: Track payment patterns and discrepancies to negotiate consistent and transparent reimbursement rates.
• Understand Payor Behavior: Evaluate which payors are most likely to approve or deny MRD testing claims. Use this data to tailor negotiation strategies and prioritize high-value payor relationships.
• Utilize Market Analysis: Compare reimbursement rates across different payors to understand market dynamics and negotiate competitive rates.

Data is your strongest ally. Monitor claims, denials, and payment patterns regularly to inform negotiation strategies and identify opportunities for contract improvements.

4. Collaborating with Medical Directors and Policy Advisors

Payor policies for MRD testing are inconsistent, often leading to coverage discrepancies for clinical indications. Collaborating with medical directors and policy advisors can help bridge this gap.

Influencing Policy Through Collaboration:

• Leverage MolDX LCD Policies: Use comprehensive MolDX LCD policies, which cover more clinical indications than commercial payors, as a benchmark when negotiating with payors.
• Engage with Medical Directors: Provide clinical data and real-world evidence to medical directors, demonstrating the value and necessity of MRD testing in improving patient outcomes.
• Advocate for Broader Coverage: Collaborate with policy advisors to influence payor policies by showcasing unmet clinical needs and leveraging industry-wide data.

Industry-wide collaboration and information sharing can strengthen advocacy efforts and help establish consistent payer policies for MRD testing.

5. Proactive Contract Negotiation & Revenue Assurance

Payor contracts significantly impact reimbursement consistency and market access. Proactive contract negotiation and robust revenue assurance practices can ensure optimal reimbursement for MRD testing.

Contract Negotiation Best Practices:

• Secure Z-Code Recognition: Since many payors require Z-codes for both 81479 and PLA codes, ensure contracts specify Z-code requirements to minimize denials.
• Include Clear Reimbursement Terms: Negotiate transparent pricing and reimbursement timelines to reduce payment delays and forecasting uncertainty.
• Address Prior Authorization (PA) Requirements: Many payors require extensive documentation to justify medical necessity, so clearly outlining prior authorization requirements and timelines in contracts can streamline the approval process and prevent denials.

Revenue Optimization Tips:

• Automate Claims and Denials Management: Leverage AI-driven automation for prior authorization, claims submissions, and denial management to minimize errors and improve efficiency.
• Monitor Underpayments and Overpayments: Use BI tools to track payment discrepancies and appeal underpayments. Overpayments should also be monitored to avoid future audits and recoupments.
• Focus on Contract Compliance: Regularly audit claims to ensure compliance with contractual agreements and proactively address discrepancies.

• Streamline the Prior Authorization (PA) process: PA remains a significant barrier to MRD testing reimbursement, often leading to delays and denials. Streamlining the PA process can significantly reduce bottlenecks, ensuring faster approvals and improved reimbursement outcomes.

  • Automate PA Management: Utilize AI-driven tools to track PA requests, reduce manual errors, and accelerate approvals.
  • Develop Standardized Clinical Documentation: Ensure that test orders include payor-preferred medical necessity criteria, such as NCCN guidelines and peer-reviewed studies supporting MRD testing.
  • Engage with Payors Proactively: Work with medical directors to establish clear PA criteria, minimizing unnecessary rejections.
  • Monitor PA Trends & Denial Patterns: Leverage analytics to identify common denial reasons and adjust documentation strategies accordingly.

By implementing these strategies, laboratories can reduce PA-related delays and improve access to MRD testing for patients.

Payor negotiations and market access for MRD testing are complex but achievable with strategic planning, data-driven insights, and effective collaboration. By choosing the right coding strategy, negotiating bundled payments, leveraging data analytics, collaborating with medical directors, and proactively managing contracts, laboratories can secure optimal reimbursement and expand market access for MRD testing.

To succeed in the dynamic landscape of MRD testing, laboratories must adopt a comprehensive, data-driven approach and engage in industry-wide collaboration to influence payor policies. By implementing these five strategies, your laboratory can navigate payor complexities, maximize reimbursement, and ultimately provide better access to lifesaving MRD testing for cancer patients.

Clarisa Blattner recently presented at the Semi-Annual Diagnostic Coverage & Reimbursement Conference on Navigating the Clinical and Financial Complexities of MRD Testing. Click here to download her presentation. Contact our team today to learn more about billing and reimbursement strategies for MRD testing.

Additional Resources