Discounts Don’t Equal Savings

Our solutions provide real value and deliver proven savings of 10–20% on outpatient lab spend to over 30 health plans serving more than 44 million members. Fee schedule discounts are insufficient to manage lab spend and combat lab practices such as volume-shifting, cost-masking, and generic code utilization, which obscure test intent and complexity, weaken claim defense. As an independent laboratory benefit management partner, we assist health plans and lab partners in delivering appropriate testing, strong clinical justification, and evidence-based utilization, which reduce waste, enhance claim defensibility, and ensure testing aligns seamlessly with payer policies.

Partner With Trusted Lab Stewards

Avalon stewards care by elevating quality, transparency, and independence while removing waste and delivering demonstrated savings.

Enforcement Based on Science

Medical necessity is essential to laboratory stewardship programs and compliance with the OIG mandate. Our programs enhance compliance efforts by ensuring appropriate test ordering for medical necessity, improving quality, and reducing cost. 

Preventative Care Integration

Avalon policies follow evidence-based practices and national guidelines, such as OIG, Choosing Wisely, and ASCP guidelines, ensuring that wellness testing is clinically appropriate.

Fully Transparent

Avalon policies are reviewed by our independent Clinical Advisory Board. Avalon’s health plan clients have full control over the adoption and adaptation of policies, including variances.

Provider-Friendly Tools

Avalon supports ordering providers via education, policy visibility, and defensible, evidence-based edits. Denials are justified and based on the health plans' adopted policies. Reconsideration/appeal rates for Avalon programs are low <.01%.

Myth vs. Fact

LBMs are not driving provider behavior change

  Avalon supports ordering providers via education, policy visibility, and defensible, evidence-based edits. Ordering providers and patients are not impacted and  reconsideration/appeal rates for Avalon programs are very low (<.01%.). Proven savings demonstrate behavior change impact- ~7.6% averted costs on average POS 81 with savings 10-20% for outpatient lab spend.

Routine wellness testing is overly restrictive

Avalon’s science-based policies, developed with lab expertise and an independent Clinical Advisory Board, cover over 20,000 lab tests. Our health plan clients retain full control over the adoption and adaptation of policies, including variances.

The outpatient lab denial rate with LBMs is >30%

Our actual denial rate ranges from  6–10% and is backed by clinical evidence. Lab providers often misrepresent this by including all denial types (e.g., PI).

Exclusive networks negate the need for LBM programs

Exclusive lab contracts may offer some cost control, but they limit patient access, reduce quality, increase out-of-pocket costs, and remove oversight of lab utilization. Our analysis shows that plans switching from exclusive networks to Avalon programs with RTM policy edits for POS 81 achieve over 10% savings.

LBMs interfere with preventive care

Avalon policies follow evidence-based practices and national guidelines such as OIG, Choosing Wisely, and ASCP guidelines. Wellness edits are clinically appropriate and science-backed.

LBM policies lack transparency into post-service edits and decision rationale

Avalon offers rigorous and thorough policies that incorporate multiple perspectives and evidence-based sources and are reviewed by our independent CAB. Our proprietary technology (APEA) provides decision reasoning, defensible criteria, extensive information on billing processes (CPT codes, edit types, fixed criteria), and provider education on appropriate utilization provided by Avalon. 

Strategic and Effective LBM partners

Avalon transforms lab management into measurable, value-based care using a scalable, science-driven frameworks that unlock the full value of diagnostic intelligence. Unlike other “lab stewardship” programs, our solutions provide tools and critical insights to take back control from lab-owned management programs.  

Evidence-Based Science that Delivers Results

Lab Expertise You Can Trust

Technology That Drives Affordability

Connect with us to learn how we’re transforming lab management to better serve health plans, providers, and members alike. 

  Resources, Education & Insights

Discover the Hidden Benefits of Lab Benefit Management for Health Plans and Members

Improving Price Transparency in Labs and Beyond 

Four Ways Lab Benefits Management Helps Patients

2025 Avalon Lab Trend Report

Payment Matters: Understanding Payer Perspectives on Laboratory Stewardship 

Lab Claim Integrity: A Vital Component of Healthcare Quality and Cost Containmen