Clinical Lab Billing Services
Specialized clinical laboratory billing & RCM recover more revenue from lab testing, reduce denials, and automate repetitive work with AI-powered billing that thinks like a lab tech.
Running a clinical lab is technical, fast-paced, and full of tiny details that add up: CPT panels, CLIA and payer rules, referral tests, and unit/quantity lines. At Sirius Solutions Global, we combine lab-domain billing experts with AI-augmented workflows to stop revenue leaks, speed reimbursements, and give your lab leaders clear, actionable financial insights without stealing time from your bench work.
What we deliver lab-first end-to-end RCM
We don’t just file claims. We optimize the entire lab revenue pipeline.
Front-end: eligibility & billing rules checks
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Real-time payer eligibility checks at order capture.
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Intelligent pre-billing checks for panel vs single-test logic and CLIA validation.
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Flag tests requiring prior authorization or specific payer documentation.
Charge capture & code validation
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Map test orders (LIS) to CPT/HCPCS codes and ensure units are correct (panels vs components).
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Validate CLIA IDs and apply referral modifiers when external referral labs perform testing.
AI-powered claim scrubbing & coding assistance
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AI suggests appropriate CPTs and flags likely mismatches between the LIS order and claimed codes.
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Rule-based + ML scrubbing catches common lab edits (panel bundling, unit mismatches) before submission, raising first-pass acceptance. (See industry examples where AI automations cut manual hours dramatically).
Clean electronic claims & payer-tailored submission
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EDI with payer-specific templates, correct CLIA & taxonomy fields, and lab-referral flows.
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Immediate resubmission of corrected claims using automated workflows.
Denial management & appeals
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Root cause analytics to find systemic denial drivers (e.g., specific CPTs or payers).
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Clinically-backed appeals with chain-of-custody and lab documentation when needed (test accession logs, report timestamps).
Collections & patient billing (if applicable)
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Transparent patient statements for outpatient lab draws.
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Payment plans for high-cost specialty testing where needed.
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Reporting & KPIs
· Weekly dashboards: first-pass acceptance, denial rate by CPT & payer, days-in-A/R, net collection rate.
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Actionable revenue playbook: top 10 deniers, top 10 denied CPTs, and remediation cadence.
Outcomes you can expect
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Higher first-pass acceptance: fewer rejects by validating CLIA/NPI, payer templates, and CPT combos upfront. (Typical lift depends on baseline; many labs see quick gains.)
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Denial rate reduction: targeted remediation on top denial drivers (eligibility, code/diagnosis mismatch, referral) reduces denials and rework.
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Improved cash flow & shorter A/R: prioritized follow-up on high-dollar molecular claims shortens days-to-pay.
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Audit readiness: detailed documentation and pre-bill checks reduce exposure to recoupments.
Why clinical lab billing is a different
Clinical labs aren’t general medical offices. A few of the things that make lab billing unique:
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CPT complexity in the 80000–89999 range. Routine chemistries, immunoassays, hematology, microbiology, pathology and molecular tests are coded in this block and many tests are packaged or require special modifiers. Mistakes in code combos and bundling cause denials.
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CLIA & lab identifiers matter. Medicare and many payers require CLIA numbers (and sometimes both billing and reference lab CLIA numbers on referral tests). Claims missing CLIA or with incorrect CLIA/NPI combos get rejected or delayed.
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Referral and split-billing rules. Referral tests sent to external reference labs have special billing flows (e.g., the 90 modifier for referral lab tests) and sometimes require both lab IDs on the same claim. Getting referral flows right saves rework and shows compliance.
Payer-specific frequency & medical necessity checks. Many payers limit how often a test is allowed or require specific diagnosis justification for panels; automated rules can catch non-covered repeats before submission.
Common lab billing scenarios we fix
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Referral test rejected because CLIA ID missing: we attach CLIA numbers and resubmit with the proper referral modifier.
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Panel mis-billed as individual tests: our pre-bill scrub corrects the claim mapping or consolidates units to match payer expectations.
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High-volume denial from a single payer: denial analytics find the root cause (e.g., missing NDCs or incorrect CPT modifiers), and we create a cross-functional fix (billing rule + lab order template change).
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SARS-CoV-2 / molecular testing variances: we maintain payer-specific logic for PCR and molecular assays (which carry unique coverage conditions).
How our AI-Powered Billing helps clinical labs
You asked for real, humanized AI info here’s how our AI helps in concrete terms:
1. Automated code suggestion from LIS/EHR orders
Our AI reads order text, maps it to the most-likely CPT codes, suggests units, and surfaces mismatches for human review cutting coder review time and reducing miscoding. (NLP-based coding tools are now shown to speed processing and reduce errors.)
2. Claim-scrub layer that learns
Beyond static payer rules, our ML models learn from past denials and predict which claims are at high risk. High-risk claims are auto-flagged for pre-bill human review. This reduces denial volumes and improves first-pass acceptance.
3. Document understanding & data extraction
For referral tests or complex lab panels, AI extracts CLIA numbers, accession IDs, and lab report timestamps from unstructured documentation to attach to claims — mimicking what a senior biller would do, at machine speed. Case studies show substantial hourly savings when automations handle routine extraction.
4. Predictive denial prevention & prioritization
AI ranks denials by expected recoverable value and probability, so your team focuses on the highest-dollar, highest-impact accounts first.
5. Continuous payer policy monitoring
AI agents scan payer updates, CLFS files, and LCD changes and create recommended rule updates for claim scrubbing reducing lag between policy change and system update. (CMS CLFS updates are frequent enough that automation materially reduces mis-billing risk.)
Bottom line: AI doesn’t replace clinical billing expertise it amplifies it. You get the speed and scale of automation, plus human oversight where nuance matters.
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If billing is stealing time from patient care, let’s change that.
Request a complimentary baseline audit and get a clear, personalized action plan to streamline your revenue cycle.
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