Test management: how to avoid wasting resources

This scene is common in hospitals: at 7 a.m., the emergency department is already full. A patient with chest pain enters the protocol, and in less than 15 minutes lab tests, cardiac markers and a CT scan are ordered. Hours later, some of these tests turn out to be redundant. The clinical outcome was appropriate, but the unplanned cost remains. And that cost does not show up only on the hospital claim, but also indirectly in denials and in the team’s time consumed.

A lack of governance over indications, protocols and integration with billing can lead to waste. This is where test management plays a strategic role in the institution. Its main goal is not to order fewer tests, but to ensure that each one produces clinical value and financial sustainability.

How does test management affect clinical and financial results?

Efficient management of lab and imaging tests depends on the institution’s ability to see the diagnostic flow in an integrated way, from the medical order to billing.

Diagnostic medicine processes billions of tests a year in Brazilian private healthcare. With this volume, it is essential to control the entire path of the test: from the medical indication to final billing. When each stage is tracked, the institution reduces errors, repeat tests and financial losses.

This tracking helps eliminate three frequent errors:

• duplicate tests within inappropriate clinical windows;

• unjustified variation between physicians or specialties;

• orders that do not comply with scientific and contractual guidelines.

How does interoperability reduce repeat testing?

Interoperability is the ability of different systems to “talk” to each other. The electronic medical record, the lab, imaging and billing need to share data in a secure and standardized way.

This avoids common situations: the patient takes a test in one department, but the information does not appear in the ordering physician’s system. Result: unnecessary repetition.

When the diagnostic history is available at the moment of the clinical decision, the physician can confirm recent tests, assess lab trends and avoid repeats without an indication.

The less waste, the lower the exposure to denials and the faster the clinical decisions.

This sharing must comply with Brazil’s General Personal Data Protection Law (LGPD).

Why are evidence-based protocols essential?

Clinical protocols reduce subjectivity. They define when a test is indicated, in what context and by what criteria.

International initiatives such as Choosing Wisely reinforce the importance of avoiding tests of low clinical value. In Brazil, this alignment also needs to take into account the ANS (Brazil’s National Supplementary Health Agency) Utilization Guidelines (DUT).

When the order is grounded in a protocol, auditing becomes more technical and less opinion-based, the risk of denial decreases and the technical defense in case of questioning becomes stronger.

What practical strategies support efficient test management?

High-performance test management is built on three operational pillars:

• Real-time monitoring: tracking the volume, profile and variation of orders makes it possible to quickly identify tests outside protocol, operational bottlenecks and excessive consumption of supplies.

• Continuing education for the medical staff: constant updates on utilization criteria, scientific evidence and economic impact reduce low-value orders and strengthen a culture of responsibility in care.

• Concurrent audit: validating clinical necessity, coding and adherence to the DUT while the patient is still being treated prevents denials, rework and later financial losses.

Mature institutions use clear indicators, such as the test repetition rate, the percentage of protocol adherence and denials avoided before discharge, to measure the effectiveness of these strategies.

How does artificial intelligence strengthen clinical governance?

The high volume of diagnostic data makes manual analysis enormously difficult. Artificial intelligence acts as a layer of support for decision-making and auditing.

In practice, AI can:

• identify duplicate tests within critical periods;

• detect protocol deviations by specialty;

• cross-check orders against clinical history;

• flag inconsistencies before submission to billing;

• prioritize reports with critical findings.

The Rivio view

Diagnostic medicine only creates value when there is governance over data, protocols and contracts. This is where artificial intelligence can be a game changer in avoiding waste, integrating care, regulatory and contractual information in real time.

With Rivio’s AI platform, it is possible to automate critical stages of the hospital revenue cycle: from care and medical audit to XML submission, including denial appeals after the payers’ review.

The platform was built to identify discrepancies, prevent invisible losses, reduce denials and ensure the hospital receives the full amount it is entitled to. By contract, Rivio commits to reimbursing the hospital 100% if a denial is not reversed.