Mastering NIPS Revenue Challenges with the Right RCM Approach

Non-Invasive Prenatal Screening (NIPS), also known as Non-Invasive Prenatal Testing (NIPT), has become a widely adopted tool in prenatal care, offering early insights into chromosomal conditions. Yet despite its clinical value and increasing payor coverage, laboratories continue to face significant reimbursement challenges. From complex payor policies to inconsistent denial reasons, the NIPS billing landscape remains a minefield.

This blog unpacks the top reimbursement issues in NIPS testing and explores how purpose-built RCM tools and strategies can help labs maximize reimbursement and reduce administrative overhead.

Reimbursement Roadblocks in NIPS Testing

Even with broader payor adoption, reimbursement for NIPS is far from guaranteed. Labs continue to experience denials due to:

• Restrictive Coverage Practices: While some commercial payors now cover NIPS for all pregnancies regardless of risk, many Medicaid and regional plans restrict coverage to high-risk pregnancies—such as those involving advanced maternal age, abnormal ultrasound findings, or a personal or family history of chromosomal abnormalities—creating inconsistencies in reimbursement and access.
• Inconsistent Payor Policies: Many denials occur despite a lab meeting the documented policy requirements. For instance, payors may deny claims where proper documentation exists, or policies are inconsistently enforced.
• Prior Authorization Pitfalls: Several payors still require prior authorization, and the failure to obtain or document this appropriately is a frequent cause of denials.
• Documentation Gaps: Payors want to see detailed, structured documentation—such as confirmation of gestational age (typically 9+ weeks), viability of pregnancy, and any genetic counseling provided.
• Expanded Testing: Adding microdeletions or non-standard conditions to a NIPS panel often leads to non-coverage, as payors view these as not medically necessary.
• Multiple CPT/PLA Codes with Limited Recognition: NIPS testing is billed under CPT codes like 81420 and 81507—or under PLA codes. However, not all codes are recognized or reimbursed equally by all payors. Some Medicaid plans, for example, only accept 81420 regardless of the actual test methodology used.

How the Right RCM Partner Makes a Difference

A next-generation RCM platform tailored for molecular and genetic testing brings much-needed clarity and control to a complicated process. Here’s how:

1. 1. Intelligent Appeal Management

Automated appeal workflows help labs rapidly respond to denials—especially for cases where payor policy has clearly been met. For example, pre-populated appeal letters based on denial reason and payor policy can reduce turnaround time and improve success rates.

1. 1. Purpose-Built Requisition Design

Labs can partner with their RCM teams to understand medical necessity documentation requirements and customize requisitions to ensure information is documented upfront—such as prenatal counseling confirmation, gestational age, and clinical indications. This can help reduce denials and strengthen appeal post-denial.

1. 1. Real-Time Payor Policy Intelligence

Understanding the nuanced coverage criteria of major payors (Aetna, Cigna, UHC, Medicaid plans) is essential. RCM solutions that actively monitor payor policies and flag compliance gaps before submission can significantly reduce denials.

1. 1. Test and Client Profitability Reporting

NIPS testing involves high costs and tight margins. Knowing which clients submit high-risk claims or which CPT codes result in frequent denials allows labs to take proactive steps—whether it’s client education, contract renegotiation, or test strategy refinement.

1. 1. Data-Backed Contract Negotiations

Labs engaged in payor contract discussions benefit from aggregated reimbursement data across peers. Understanding industry-wide trends provides leverage in negotiations and helps ensure fair reimbursement.

1. 1. Cross-Client Benchmarking Trends

Partnering with a vendor that handles NIPS testing for multiple clients enables valuable insight into payor behavior. Shared denial patterns and evolving coverage criteria can be identified early, helping labs make informed decisions about billing strategies and market expansion opportunities.

As the NIPS testing market matures, so too must the tools that support it. A robust RCM solution doesn’t just streamline claims—it empowers labs with payor intelligence, automated workflows, and data-driven decisions that lead to higher reimbursement and fewer administrative headaches.

Whether you’re an established NIPS provider or expanding into this space, the key to success lies in smart infrastructure—and that starts with the right RCM partner.

To learn how our RCM solution helps labs streamline NIPS reimbursement, minimize denials, and improve profitability contact us to schedule a walkthrough.