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Benefit Management

Routine Test Management

Transform how payers manage the most utilized—and often misused—benefit in healthcare: routine lab testing.

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Lab testing is essential to healthcare, but many tests are unnecessary.

Around 14 billion clinical lab tests are performed annually in the U.S., making them the most utilized medical benefit. Lab results are involved in 70% of clinical decisions. Despite their importance, around 30% of lab tests conducted in the U.S. may be unnecessary, while another 30% of patients don’t get the test they genuinely need.

As volume and variety of tests increase exponentially, the value to patients, physicians and payers remains static. This creates a Lab value gap where 30% of tests are unnecessary and 30% of patients don't get the tests they need.

Automated, scalable adherence to scientific guidelines and evidence-based lab policies.

10–20%

savings on outpatient routine lab spend in 2024

$1-3

PMPM medical expense savings

Avalon’s Routine Test Management (RTM) solution ensures automated, scalable adherence to scientific guidelines and evidence-based lab policies. Avalon’s proprietary technology evaluates laboratory claims post-service and pre-payment in real time, using thousands of rules to evaluate claims against fixed criteria including CPT® codes, age, lab test history, and frequency. This ensures lab tests align with laboratory science and health plan policies. Since RTM operates post-service, it avoids disruption or abrasion for physicians and patients.

Our management approach for routine testing helps payer organizations and providers keep pace with the evolving science in lab medicine and ensure appropriate, evidence-based laboratory services. By reducing wasteful and unnecessary testing, our program improves quality, affordability, and drives medical expense savings, ranging from $1-$3 per member per month (PMPM).

Update evidence-based lab policies quarterly to keep abreast of the latest science

Translate health plan policies to code-level rules for automated evaluation

Enforce and adjudicate policy automatically between service and payment in near real-time

Facilitate behavior change toward policy adherence with actionable provider education tools

Key capabilities

A dedicated team of PhD-level scientists and an independent Clinical Advisory Board.

Development and maintenance, including policy updates based on emerging research and shifting lab policies.

Customizable policies align with regulatory requirements and health plan needs.

Comprehensive provider education to support adherence and behavior change, ensuring lab testing aligns with scientific guidelines.

Patented, scalable technology that seamlessly automates policy enforcement.

Translate policies to rules based on fixed criteria for automated enforcement.

Routine Test Management is where diagnostic value begins.

Avalon’s RTM solution delivers unmatched precision, efficiency, and financial impact, making it the go-to solution for health plans managing outpatient lab testing.

Beyond Payment Integrity for Correct Coding

Avalon is the only company offering an automated Routine Test Management solution that ensures lab testing adheres to science-backed, evidence-based guidelines. This results in significant savings for both health plans and their members, beyond the plans’ payment integrity and network efforts.

Avalon’s proprietary lab policies are rooted in rigorous scientific research, developed, and maintained in-house by full-time scientists. Each policy undergoes a thorough internal and external review, backed by an average of 50 scientific references.

Avalon’s policy research team—comprising technologists, biostatisticians, clinicians, PhDs, and coders—specializes in laboratory science and policy development. Additionally, our independent Clinical Advisory Board (CAB), led by top experts in laboratory medicine, reviews and approves policies annually or as scientific advancements dictate.

RTM delivers real-time, automated decision advice, post-service, pre-payment, backed by clear policy references. This ensures fair, transparent claims processing, strengthens compliance, and enhances defensibility—empowering health plans with data-driven support for provider relations.

Avalon offers education, adherence reporting, and a Trial Claim Advice tool to help providers understand and adhere to policies, leading to <0.01% reconsideration rates.

Let’s unlock the power of diagnostics together.

Contact Avalon to learn how our Routine Test Management solution helped a regional plan save $112M.

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