Lucid Diagnostics Inc
NASDAQ:LUCD
Earnings Call Analysis
Q4-2023 Analysis
Lucid Diagnostics Inc
The company has witnessed a healthy increase in test volumes without expanding the sales force. They ended the last quarter with 2,400 tests conducted and expect this to hold or grow modestly in the coming quarters, despite three weeks of inactivity due to holidays and a national sales meeting. This shows an effective uptick in productivity with the existing sales structure. The company remains cautious, choosing not to increase the sales force until more progress is made on the reimbursement side.
CheckYourFoodTube, a pre-cancer detection event for firefighters, contributes significantly to the company's activities, with a strong pipeline fully booked through July. The test volume growth potential is now also tied to direct contracting initiatives, not just health fair events. With increasing engagement across several fronts, like benefit programs and entities such as unions and residential communities, the company is expanding its reach. Direct contracting offers three models: per patient testing contracts, lifetime benefits per member, and service agreements for on-site events.
Efforts on the Medicare front are intensifying with anticipated reengagement with the MolDX program that finalizes local coverage determinations. The publication of key clinical studies is set to clear the path for Medicare coverage. Meanwhile, biomarker legislation is in motion across over a dozen states, which could potentially impact the reimbursement landscape positively.
The company ended the year with $18.9 million in cash and completed a financing round for an additional $18.1 million. However, the ability to fund operations beyond a year hinges on revenue growth which, in turn, is dependent on reimbursement outcomes and corporate finance activities. Subsequent to year-end, Lucid settled $4.7 million in debt to PAVmed through equity, marking the common shares outstanding at 48.2 million.
Quarterly revenue rose by 33% sequentially, totaling $1.04 million, and reflects significant increases over previous periods. This includes both actual cash collections and billable amounts contracted directly with employers. Revenue recognition, however, depends on the collections’ probability given the early stage of the reimbursement process. Total non-GAAP operating expenses for the quarter were $10.9 million, showcasing a stable year-over-year expenditure and reflecting investment in key areas.
Under the new revenue cycle manager, 7,800 claims worth approximately $20 million have been submitted with 46% resulting in an allowable amount, averaging $1,828 per test. Despite the administrative process involving patient deductibles and out-of-pocket expenses, the consistent pricing across out-of-network tests is a positive signal.
As the company expands its CheckYourFoodTube events and applies direct contracting, they plan for significant growth in test volume that's not entirely dependent on sales force productivity. They have encountered high demand for events but are currently limited by the clinical team's size. The company will consider investing more in clinicians for event expansion as they see successful conversions from these events’ revenues.
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Good morning, and welcome to the Lucid Diagnostics Fourth Quarter and Full Year 2023 Business Update Conference Call. [Operator Instructions] Please note this event is being recorded.
I would now like to turn the conference over to Dennis McGrath, Lucid Diagnostics' Chief Financial Officer. Please go ahead.
Thank you, Ludy. Good morning, everyone. Thank you for participating in today's fourth quarter and full year 2023 Lucid Diagnostics Business Update Call. The press release announcing our business update for the company and financial results for the fourth quarter and the year ending December 31, 2023, is available on our Lucid website. Please take a moment and read the disclaimer about forward-looking statements in the press release.
Business update, the press release and this conference call include forward-looking statements, and these forward-looking statements are subject to known and unknown risks and uncertainties that may cause actual results to differ materially from statements made. Factors that could cause actual results to differ are described in the disclaimer and in our filings with the U.S. Securities and Exchange Commission.
For a list and description of these and other important risk factors and uncertainties that may affect future operations, see Part I, Item 1A entitled Risk Factors in Lucid's most recent annual report on Form 10-Q filed with the SEC and subsequent updates filed in quarterly reports on Form 10-Q and any subsequent filings on Form 8-K.
Except as required by law, Lucid disclaims any intentions or obligations to publicly update or revise any forward-looking statements to reflect changes in expectations or in events, conditions or circumstances on which the expectations may be based or that may affect the likelihood that actual results will differ from those contained in the forward-looking statements. I'd like to turn the call over to Dr. Lishan Aklog, our Chairman and CEO of Lucid Diagnostics. Lishan?
Thank you, Dennis, and good afternoon, everyone. Thank you for joining our quarterly update call today. Before proceeding, a couple of things. First, I'd like to pause as I have a bit of a scratchy throat. I'm feeling a bit of weather. So sorry about that.
And I'd also like to thank our long-term shareholders for your ongoing support and commitment. Hopefully you know our team is singularly focused on driving the Lucid enterprise towards its massive commercial potential and to enhance our long-term shareholder value.
So I'm very pleased with the excellent progress that Lucid has made on multiple fronts during the fourth quarter and the start of this year, including strengthening our balance sheet with about $18 million financing from long-standing fundamental shareholders.
We saw solid revenue growth on stable test volume, improving allowances and stable out-of-network pricing. Our CYFT program the health fair events is driving are now robust clinical validity and clinical utility evidence based are poised to drive positive medical coverage and what I believe is at line of sight to medicare coverage. And I'm also particularly excited about our accelerating direct contracting initiatives.
So just -- let me just offer a few highlights, and then I'll do a quick overview of the company for those of you who are new. On the commercial execution side, the fourth quarter revenues were just a hair over $1 million. That's up 33% quarterly and 829% annually. EsoGuard test volume was 2,200 tests. I'll talk a bit more about those trends later. High-volume health fair CYFT testing events continue to gain traction, and we're fully booked right now through July.
We have active EsoGuard testing programs now at over a dozen strategic accounts, which include health systems, academic centers and other related entities. And we have engagements with several dozen more. Our revenue cycle management process continues to deliver solid results for out-of-network payments, about 50% of adjudicated claims are now coming back and the loud with stable payments averaging about $1,800.
Next slide. Some key strategic accomplishments. As I mentioned, we restrengthened our balance sheet with the $18.1 million preferred stock financing. We've had a significant expansion of our clinical validity or CV at our clinical utility or CU data to support broad EsoGuard medical policy coverage, including engaging -- reengaging with MolDX for the Medicare side, which I'll talk about a little bit later.
We've seen now 3 clinical validity studies that document excellent EsoGuard sensitivity and negative predictive value. We have 3 clinical utility studies that document near perfect concordance with physician decision-making. Using that data, we're now starting to hold meetings. We've held meetings now over the last couple of months with medical directors of major commercial payers to now for the first time, formally request positive medical policy determination for EsoGuard.
Similar to those efforts, we held a Blue Cross Blue Shield Association of America webinar that was attended by dozens of medical directors to advocate for EsoGuard coverage. And then finally, we'll talk a bit more about this later. We've launched our direct contracting program with EsoGuard now offered as a benefit and this as a means to drive contractually guaranteed revenues.
Just a few intro slides for those of you who are newer to update you on our company overall. Lucid is a commercial stage cancer prevention, medical diagnostics company. We're focused on early pre-cancer detection to prevent esophageal cancer deaths in targeted at-risk patients. Next slide.
The EsoGuard esophageal DNA test is the first and only commercially available test that's capable of serving as widespread screening tool to prevent these deaths through the early detection of esophageal pre-cancer. Next slide.
So now we have -- as I mentioned, we have really solid clinical validity data that documents EsoGuard's performance. This is a bit of a summary slide here. EsoGuard is in blue and comparing it to sort of the standards that we see for performance with other tests, particularly in the colorectal space, with Cologuard and the new blood test at Guardant. Cancer sensitivity remains extremely high as does pre-cancer sensitivity and early pre-cancer sensitivity.
And those 2 numbers, I'll note, are really unprecedented. So to have a 90% pre-cancer sensitivity, again, you can now compare to other tests in the space, is unprecedented. There is no other molecular diagnostic test that can claim that and most notably, our early pre-cancer numbers also holding in at that 90% range.
Again, no other tests, molecular tests can detect early pre-cancer with any sensitivity much lesser than 90% level. That results in an overall negative predictive value of 99%, so just 1% false negative rate and an estimated positive predictive value of 30%, which increases the yield of endoscopies between 2 and 3 fold. Next slide.
Just 2 slides summarizing this data. Again, this is the absolute foundation, the backbone of our future is documenting the performance of the study. Clinical validity, again, is the performance of the assay here. I won't go through each detail here, but you can see that we have 3 studies, the original Case Western paper, the BETRNet study and Cleveland VA. One is published, 2 are in preprint. And coming soon, we have a manuscript completed for the BE-1 study, which is now heading towards posting on preprint and submission for publication.
Next slide. Similarly, on the clinical utility side, we had now 3 studies that are published in the peer-review literature and form, again, the foundation of our engagements with payers -- commercial payers, and in the near term with Medicare.
Next slide. The market opportunity here is really fantastic. It's massive. There are absolutely 30 million patients who are at risk, are recommended for pre-cancer testing by existing guidelines, which now include non-endoscopic biomarker testing, such as EsoGuard. We have Medicare payment established at $1,938.
As I noted, our out-of-network payments are matching that quite closely at about $1,800 so that pricing is holding. And that results in an approximately $60 billion true total addressable market opportunity. Our gross margin is 90% at our current volumes. So at our current levels of efficiency. Next slide.
And our commercial strategy is multipronged. So patients -- our goal is to provide patients access wherever we can. So we have our own physical Lucid test centers. A backbone, a major pathway for patient access is the satellite Lucid test centers where our practitioners go to physicians' offices on scheduled days and test patients in their offices. We also have physician practices, particularly GI practices and other specialists, who perform the EsoGuard test using their own staff. That accounts for about 30% of our total volume.
In Florida, we have a mobile Lucid test center, a van that can go to physician practices, park in the parking lot, pitch a tent and offer testing on the spot. And as we'll talk about a little bit more, we have our CheckYourFoodTube health fair events, which have been focused initially over the past year. We've reached our 1-year anniversary at these health fair type events and are expanding into other areas as well.
Next slide. So this slide shows our the progress over the last approximately per years with regard to revenue and test volume growth. So you can see revenue has been growing nicely since our transition in the late second quarter to our new revenue cycle management provider. So the late second quarter of 2023. The test volume growth has stabilized. And we think this is likely going to be approximately where things stabilize at sort of the 2,300 to 2,500 range.
I will note and remind you that we have not added any salespeople since the fourth quarter of 2022 so that growth from about 1,000 tests to this 2,400 plus or minus level has been with the same sales force. And as I hinted earlier, we've had increases in productivity. However, we have no plans at this point to expand our sales force until we continue to see some progress on the reimbursement side. So that's our expectation.
In the fourth quarter, we had 3 weeks that were -- where we weren't able to do testing, between 2 holidays and 1 week for our national sales meeting. And so we feel pretty comfortable that these volumes will hold and we'll show potentially modest growth over the coming quarters. I did indicate an estimated number for the quarter that's just about to close. Next slide. So a little bit deeper dive on our commercial execution. The CheckYourFoodTube, our health fair type pre-cancer detection event remain a significant contributor to our activity. As you can see on the right there, these have been heavily focused on firefighters since we had our first event now just over a year ago in San Antonio, we've had steady growth. We have some very strong pipeline, and we're fully booked through July. Right now, our rate limiting factor is the number of clinical personnel we have to run these events, and we have a really great demand from entities, particularly the firefighters.
We're expanding our testing beyond just holding health fair events at firehouses to now targeted conferences. We actually had an event at the national conference for firefighter chiefs and tested several dozen firefighter chiefs on the spot during the conference and other Texas symposium. We're increasing the efficiency of these events and their capacity by utilizing UpScript, our telehealth partner, so we no longer have to identify a local physician champion to get one is off of the ground. We can just jump in and get started with our telehealth partner. And really, perhaps most importantly, the last bullet here, we're now -- as we launch these events, we're now initiating contracting discussions in parallel with planning for the initial inaugural event.
And we found that the leaders are strongly motivated to engage. For example, with the unions, there's very much, on the firefighter side, a strong motivation to offer testing and to show that they're providing something to value and they're focused on cancer prevention amongst their brothers and sisters. And that's been really encouraging and promising with regard to our ability to engage on contracts moving forward.
As I mentioned last quarter, we've been pushing harder now with our commercial team on strategic accounts. These include health systems, large multi-location group practices, academic medical centers. And now we have over a dozen such strategic accounts, including big academic medical centers that are testing, offering EsoGuard testing. And these are typically in the context of a structured overall program for esophageal cancer awareness for GERD and so forth. And we have several dozen that remain in the pipeline. On the next slide, the next big, big area for us right now is direct contracting. As we mentioned in our last call, we are getting -- just getting started with this. We hired a VP of Employer Markets, and we actually are now expanding that team. So let me just give a few more details on the next slide of what this is.
Next slide. So when we talk about direct contracting, we're talking about offering EsoGuard as a covered benefit to drive contractually guaranteed revenue. So this is different than the traditional path, the traditional path being a physician prescribes a test and we submit a claim to the insurance policy and work through, work with the insurers to get coverage and payment for that.
This essentially bypasses that and we go directly to entities with whom we can engage -- with whom we can contract to offer testing as a covered benefit typically within a health and wellness benefit program. And our team that's now about to expand is engaged with this on multiple fronts. So there's a whole network of benefit brokers that work with third-party administrators to offer benefit packages to employers across the country.
And we have now deep engagement with these entities to offer EsoGuard within the benefit packages that these brokers and ultimately, the third-party administrators are both providing to employers to offer EsoGuard as a benefit. A subset of that are self-insured entities. So with them, we can actually go directly to those entities. These again involve employers and then entities -- other similar entities such as unions who can offer our test as a service directly for their employees or members really separate from the benefit process. And we're active in that. We previously announced we've had our first contract there. Testing is -- has proceeded. And these testing events are very similar to the CheckYourFoodTube events, where our team shows up at sites for the employers and offers testing on-site to subgroups of employees or members who are candidates for testing.
And then there are other partners that we're working with. We had previously announced that we are engaged with the 9/11 Fund that has a large number of patients in the Greater New York area who are to receive treatment for conditions that are related to their exposure to 9/11. That process, there was navigate the sort of clerical issue back a couple of months ago, but that process is now back in full swing. We've formally engaged with one of their Clinical Centers of Excellence, Mount Sinai, and we look forward to starting to engage and test patients within -- who are covered by the fund. And there are a variety of other entities, for example, like residential communities in various parts, particularly in the Sun Belt, where that have concierge medicine practices that, again, offer specialized testing as a benefit for the residents, their community, and we're engaged in several of those right now and look forward to consummating contracts there.
The way -- what we offer with this direct contracting are really 3 flavors. One is a direct ongoing contract. So we would basically charge per patient tested under the umbrella of one of these contracts. The second model is particularly when it's in the context of a benefit plan and offer EsoGuard as a covered benefit. It's a charge for a lifetime benefit per member, not necessarily those who are tested.
And then we also are in discussions in several examples of just a service agreement where we charge for a full or half-day screening event that's up to a certain -- that can handle up to a certain number of patients in a given day, and those are scheduled accordingly. So that's our direct contracting initiative, a big deal. We're pushing hard on this, and we really do expect this to be a meaningful contributor to test volume as well as the revenue in the coming quarters.
Next slide. Just an update on the entire process by which we submit claims, receive payments on those claims and generally pursue in-network coverage on the revenue cycle management side. Again, this represents a payment for out-of-network claims, and we've submitted now since we made our transition to Quadax, our new revenue cycle management provider in June, about $20 million of pro forma revenue in the claims submitted represent that.
We're now quite stable at about 80% are getting adjudicated and of those that are adjudicated, an increasing percentage now, a bit over 50% are being allowed. So those -- the claim is allowed and the average allowed payment is $1,800, and we can actually go and collect that either from the payers or ultimately from the patients.
We're also working very hard with Quadax on the appeals process. We're starting to yield some wins. We're winning about 25% of our appeals. And there's an entire process by which we're -- that we're strengthening and optimizing, and that includes, for example, leveraging providers. So in certain examples, we'll get a dozen or so providers, physicians in the local area to submit to the local payer as part of an appeal to indicate the -- that this is medically necessary and important for them to cover.
And we're also working for the first time on a prior authorization program since about 18% of the denials are for lack of a prior authorization. So we're incorporating a streamlined way for physicians to seek a prior authorization.
So the big question, of course, is on medical policy coverage. I mean it's one thing for us to be collecting and the revenue that we're generating now is on out of network but ultimately to take advantage of the full potential here, we need to get in-network coverage both from commercial payers and Medicare.
So in the last month or 2, as I hinted earlier, we've held meetings with medical directors of the major commercial payers, names you would recognize, to formally request for the first time, positive medical policy determination for EsoGuard based on now the data that we have.
Now the result of those will be varied and will -- but at least it initiates a discussion. Either if we're fortunate, we'll get coverage. If we don't get immediate coverage, then our secondary goal is to get engaged in pilot programs to collect clinical utility data within that particular payer, and we have some really good prospects on that.
We were really excited, just last week that we participated in a Blue Cross Blue Shield Association of America webinar where dozens of medical directors were in attendance and our lead adviser and Head of our Medical Advisory Board, Dr. Nick Shaheen, who is the lead author of the American College of Gastroenterology guidelines, really gave an excellent presentation, making a very strong argument based on guidelines that EsoGuard should be covered by the plan. And so that was a very positive engagement.
On the Medicare side, we are targeting reengagement with the MolDX program, which is the entity that finalizes local coverage determination. We are able to operate within the construct of a local -- a final and effective local coverage determination that's foundational for the category of test that's in effect. And we now believe we've collected sufficient clinical validity and clinical utility data to make that reengagement.
The timing of that, of our meeting and pre-submission meeting with them is triggered on the publication of one of the key clinical validity studies, the BETRNet study and that we expect to happen any day now, at which point we will ask for a meeting. Then based on that meeting, proceed to a technical assessment submission.
So based on what's now a very concrete timeline and based on the completion of what we believe is sufficient data to convert the foundational LCD into coverage determination for Medicare, we really do believe that we now have a line of sight to Medicare coverage.
And then one final area that's been an area of strong focus is there is now biomarker legislation in over a dozen states where by state statute, there's a mandatory commercial coverage for certain biomarker tests, and that gives us the opportunity. Next slide, please. Next slide. So that gives us the opportunity to operate in these states.
So these are the 16 states with biomarker legislation, including 2 that are limited to cancer. We believe we -- and we're getting -- we're starting to get feedback that we are covered under these states -- under this legislation in certain states, and we're going to continue to push hard on that. Again, it guarantees mandatory commercial coverage where this legislation occurs.
And by achieving this, we're able to actually work on targeting our resources, whether they be our commercial team or other activities in those states. And that's something we're looking forward to yielding results in the next couple of quarters. So with that, I'll hand the reins over to Dennis to provide an update on our financials. So Dennis, take over.
Thanks, Lishan. The summary financial results for the fourth quarter and the year were reported on our press release that was published last night. On the next 3 slides, I'll emphasize a few key highlights from the quarter. I'd encourage you to consider those remarks in the context of the full disclosures covered in our annual report on Form 10-K, which was filed with the SEC last night that is available on our website. So on Slide 18 here, you see the balance sheet cash at year-end was $18.9 million. We supplemented that balance with the financing that we completed just 2 weeks ago in the amount of $18.1 million. The average quarterly burn rate for last year was $8.2 million per quarter, as you can see in the statement of cash flows in our 10-K. Burn in the fourth quarter was $6.7 million from operations and $3.4 million from paydown of intercompany debt.
We disclosed in the 10-K that our ability to fund operations beyond 1 year from today is largely dependent upon how revenues ramp over the next 5 quarters, which is highly dependent on how the reimbursement landscape for both government and private health insurers as well as successful efforts for direct contracting with self-insured employer shapes increases in payment realization of submitted claims and/or corporate finance activities.
Beyond that, there's nothing substantively remarkable about the remainder of the December 31 balance sheet. However, subsequent to year-end, in addition to the incremental $18 million of cash infusion, Lucid settled approximately $4.7 million in debt to PAVmed by the issuance of approximately 3.3 million shares of common stock. Shares outstanding, including unvested restricted stock awards, as of today is 48.2 million shares, which includes 242,000 shares issued subsequent to year-end in connection with converted notices received from the convertible debt holder. The GAAP shares outstanding of 42.3 million are reflected on the slide as well as on the face of the balance sheet in the 10-K. GAAP shares do not reflect unvested restricted stock awards.
With regard to the P&L on Slide 19. It compares this year's fourth quarter to last year's fourth quarter and similarly for the yearly totals on certain key items. Trust you'll review the information in my comments in light of the cautionary disclosure at the bottom of the slide about supplemental information, particularly non-GAAP information.
Revenue of $1.04 million for the quarter, a 33% sequential increase over the third quarter and is in line with what was previously previewed. The amount reflects actual cash collections for the quarter plus a small amount of invoiced EsoGuard test delivered to the Veterans Administration, plus about $26,000 in initial billings under the direct contract with the Ancira Auto Group.
The revenue increase reflects about a ninefold increase over the prior year quarter and about a sixfold annual increase over the prior year. Test volume at 2,200 tests for the quarter represented just over $5 million in submitted claims for the fourth quarter at our $24.99 standard pricing for the test.
For the first quarter of 2024, revenue is tracking to be on par with the fourth quarter. Revenue recognition is a key determinant of the probability of collections. And therefore, due to the fact that we are in the early stages of the reimbursement process means revenue recognition for submitted claims submitted to traditional government or private health insurance will be recognized when the claim is actually collected versus when the patient report is invoiced and submitted for reimbursement.
As you'll see in our 10-K, this is called variable consideration. It's in the jargon of GAAP's ASC 606 revenue recognition guidelines. And presently, there is insufficient predictive data to reflect revenue when the test report is delivered to the referring physician. For billable amounts contracted directly with employers and are fixed and determinable, they will be recognized as revenue when the contracted service is delivered. Generally, that means when the report is delivered to the referring physician. Our non-GAAP loss for the quarter of $9.9 million reflects about $600,000 in sequential increase compared to the third quarter and about $700,000 decrease year-over-year.
The increase in the fourth quarter was related to 3 specific onetime events and clinical research costs of about $300,000, mostly related to the events leading up to the published clinical utility studies, $300,000 in sales and marketing and some G&A patent expenses of about $250,000. These amounts were offset by the quarterly increase in revenue. On the next slide, Slide 20 is a graphic illustration of our operating expenses for the period is reflected. Total non-GAAP OpEx was $10.9 million for the fourth quarter 2023 and this is fairly flat year-over-year, an increase from the third quarter, reflects the clinical research, the onetime PAT expense and that sales expense that I just mentioned.
The cost of revenue primarily consists of EsoCheck devices, lab supplies and fixed lab facility costs. The variable cost for each test is approximately $200 or effectively at 10% to 11% marginal cost of sales for changes in test volume quarter-to-quarter.
The non-GAAP net loss per share has been relatively flat for each of the last 4 quarters, plus or minus $0.01 between each of the 4 quarters of 2023. On a GAAP EPS basis, noncash charges accounted for approximately $0.03 per share in the fourth quarter.
A little bit more about reimbursement details. So since the new revenue cycle manager, Quadax, took over in mid-June, Lishan has given you some details, there were 7,800 claims representing approximately $20 million in pro forma revenue have been submitted for reimbursement either to government or to traditional health insurers. About 82% have been adjudicated. 18% are still pending. Out of the 82% that have been adjudicated, about 46% resulted in an allowable amount.
That's basically what the insurance company says, we should be entitled to be paid with an average of $1,828 per test. Now out of that amount still has to be reviewed with the patient, what's their out-of-pocket, what's their deductible, which could lower that effective amount. But the insurance companies are holding to the general pricing line and all out of network $1,828, that should be viewed very positively in terms of the benchmark Medicare $1,938.
Of those denied, about 51% require one of 3 things, either additional information, that was about 7% of those denials or deemed not medically necessary, which is a bit puzzling, considering that the patients are meeting the guidelines, that was 26% of those denials or require a prior authorization, that's 18% of those denials. About 29% were deemed to be noncovered.
So with that, operator, let's open it up for questions.
[Operator Instructions] Your first question comes from the line of Kyle Mikson from Canaccord.
Congrats on the year and the quarter. So just looking at the volume and, I guess, like the revenues. So volume decreased quarter-over-quarter a little bit, maybe 15%, do you think you can kind of maintain these quarterly levels, but around 2,400 or so claims, I guess that makes some sense given the sales force situation, but the effective ASP, that increased like over 50%, that's great. So how should we think about maybe volume and ASP dynamics and metrics going forward given you're now kind of hitting like a nice kind of stable rate for both of those, if you like, obviously kind of progressing nicely, maybe on upper trajectory, especially on the ASP side?
Let me start with volume and then I'll hand it over to Dennis. I think you summarized it well, Kyle, that we've -- because of peaking on our productivity of our existing sales force, again, that doesn't mean that we want test volume growth. The test volume growth is going to be driven more by other aspects as opposed to our sales force that's calling directly on physicians.
So that will be driven by these -- CheckYourFoodTube testing events, which are more efficient, as you might imagine, in terms of the person power that's required to run an event that can generate 100 or more tests without as much activity on the sales side, and importantly, on the direct contracting side, right? So those could yield significant test volume growth without depending on the productivity and the size of our sales force.
So I think you're right. I think we -- at the current size of our baseline activity, traditional sales and marketing activity, I think these numbers, we expect them to hold and -- but we will obviously hope to see growth from the other pathways that I mentioned. So I'll let Dennis talk a bit more about second point.
Yes. So on collection realization, the trajectory in second quarter continue the first quarter. To the extent it's dependent upon the government and private health insurance that is tied to our sales force, that level should stay relatively flat with acceleration in the second half. To the extent that the volume picks up with the direct contracting.
And again, that is not as limited, as Lishan just pointed out, by the amount of time and selling opportunity of our sales force, there is a multiplying effect with direct contracting. And the fact that payment is guaranteed as part of that contract, not dependent upon independent third-party insurance companies that is not as predictable, that will increase realization as we move forward.
So if you just look at 2 data points, second quarter and the fourth quarter, where volumes were about the same in terms of test volume, the increase in realization is significantly higher from those 2 periods. That's a reflection of the improvements with our revenue cycle manager and the appeals process is just starting to take root. And in those examples where the appeals have been submitted, we are being successful with them, that will also help with the realization.
So we see as a general statement on the third-party insurance collection, where revenue is depending upon actual cash collections, timing is an issue there in terms of how quickly from a submitted claim do we actually get cash and that's less predictable for us, kind of maintaining that as a view of fairly flat as the direct contracting picks up, the realization will obviously go up because the payment is guaranteed.
And we can recognize revenue when we deliver the reports or deliver the service that's been contracted for, which will help speed the revenue ramp. We see all of them converging in the second half, having greater momentum. So hopefully, that gives you enough color on that particular topic.
Yes, that was fantastic. And then just on the CheckYourFoodTube events, clearly, those are going pretty well. Originally, some of us may have viewed that as like a risk, creating some lumpiness with the volume and so forth, maybe like there was some concentration there. I mean, do you have like a 2- to 3-month backlog, I mean it's pretty nice visibility and you're expanding.
Is it fair that it's definitely not like just, for lack of a better word, like an artificial or like inflated volume at this point? And how does that evolve over time? How could that funnel into like deeper penetration among the clinician base over time?
Yes. So that's a great insight, Kyle. And definitely, yes, I think in the early stages when we had our first event, and there were sort of 400 patients who were tested over 2 weekends, representing what was that, 20% of our -- little more of our volume for that quarter. Certainly, there was an opportunity to be lumpy. That's just not true anymore.
So we're doing dozens of events, smaller events, larger events and everything in between. And right now, we're limited. The demand is high, and we're really limited by our clinical team that we have a certain number of clinicians, nurse practitioners, nurses and other device administrators. And we are sort of -- the efficiencies which -- we're utilizing them in an efficient way, but getting them around to these events does limit -- we have a sort of cap on how many we can do in a given month.
So I think it's correct for this -- for you to perceive this as just another source of organic volume and growth and the ability to grow that volume is going to -- I guess what I would say is the way -- our willingness to invest in more clinicians to drive more events will be directly related to our success at converting these events from we go, do test 100, 200 firefighters and submit for their insurance policy, and we're sort of at the mercy of the claims process there.
As we convert from that process, which has been how we've been focused in the early stages over the last year, to, as I mentioned, now we are, at the same time, sort of typical scenario is we engage with the fire department, now they're soliciting us because there's good visibility at the conferences and so forth. And we talk at the same time as we are arranging our first event, we talk about engaging in a contract particularly since most of these unions are self-insured. And those dialogues are going really well.
The leaders, particularly the union leaders, are motivated to offer our service to their personnel. They're very focused on cancer prevention, particularly in the firefighter group. And so as we start seeing, it's really similar in some -- in many ways, Kyle, as we start seeing increases in realization from -- realization of revenue from these events, then we'll be justified in investing in more personnel to drive our capacity to do these events.
Okay. Yes, that was great. That was a little bit good color there. Maybe just finally, wondering about some of the timelines for the clinical validity studies particularly maybe that the VA study which I know is pending publication and everything, but I mean just like relevant to that, I feel like that's kind of important -- a good proof point. And then with BE-101 and BE-102, I guess 101 is like kind of close to being announced, everything with 102 is a little bit further back. So are these important, what's the timeline and like when do we kind of expect some color?
Yes, why don't I talk about the timelines relative to our plans with MolDX. So on the clinical validity, there's the original STM paper, there's the BETRNet study, which has released data, it's on preprint. It's gone through multiple cycles of review at a leading journal, and we really expect that to be clear for peer review publication very, very shortly.
We're just kind of waiting on what we think is the last round of responses to reviewer's comments. As soon as that is published and online, then we will request a meeting with MolDX. So that's what we believe. We believe that, that is sort of a linchpin gating item for the publication of that clinical validity study.
You mentioned the VA study as being a really important complement to that, which it got posted on preprint, it's been submitted. We're not going to wait for that for being for peer review. I expect that there's a good chance that when we have our meeting, it will either be in peer review and certainly for any technical -- by the time we get around to doing a technical assessment submission, it would be peer reviewed. The key thing I think you were hinting at with the VA study, it's our first study in a screening population.
So the original STM paper as well as the BETRNet study were both case control studies, and you always want to be able to show that you can replicate your performance in the actual intended use population in a real-world situation where you're taking people off the street who've never had endoscopy before that are categorized as having at risk and recommended for screening by guidelines. And you can actually identify disease with high performance, with a high negative predictive value and really give good, solid, positive predictive value. So that is on preprint and has been submitted and we'll wait for that to be published.
On the clinical utility side -- sorry, the remaining clinical validity studies, the next line is the BE-1 study, which is our study in a screening population. That study, the manuscript is complete, the data has been tabulated. I'll give a preview and that the data is nearly identical to the VA study. So both studies in a screening population have really nearly identical and otherwise excellent results.
So that manuscript is being finalized. The lead author is Dr. Shaheen. And so we're just getting final sign-off on that and it should be posted on preprint soon and submitted for publication. Again, we're not going to wait for that. But the 2 screening population studies will be an important supplement to our discussions with MolDX and with payers in general.
The BE-2 study, we're continuing to enroll in that study. That's not a linchpin at this point of our market access efforts. We still -- enrollments picked up a bit, it has slowed down a little bit. We've shifted to entirely U.S. studies -- U.S. centers, and we're adding a few. And that will be sort of additional complementary. That will be a third case control study on top of the STM and BETRNet study, that will be supplemental but not -- that is not sort of a linchpin of our market access strategy.
Lishan, the BE-2, is that case control? Or is that the screening population?
Yes, that's case control. So that's why -- it will just be sort of the third such case control study and will be supplementary, but it's not sort of at the heart of what we -- we think we have sufficient case-control CV data and now 2 screening population CV drive to drive our market access efforts.
Your next question comes from the line of Joseph Conway from Needham.
Maybe just one on operating expenses. If you guys are planning to keep volume fairly level as well as the sales force before reimbursement comes in. But maybe seeing more traction on these CheckYourFoodTube events and what have you. I guess with all of that together, is it safe to say that we should expect a modest increase maybe in operating expenses, just on a run rate maybe on the last 2 quarters, do you think that's maybe stabilized, I guess, is a better way to say it or ask that?
Yes. So the OpEx on a GAAP basis for the last couple of quarters has been in the $12 million or so range. And the triggers for us are clearly on realization of payments. And so with the multiple streams, revenue streams, they will have different influences on where that OpEx goes.
To the extent that policy -- insurance policy changes positively at a quicker rates, we will start adding additional salespeople because that means calling on physicians.
On the direct contracting side, that typically requires less selling resources. Now we've adding to -- expanded that group from 1 to 2 or in the process of expanding from 1 to 2 because that pipeline is growing rather fast. The sales cycle there is a little bit longer but once it gets started, the test volume, the ability to increase test volume and therefore, payment associated with that, is more dependent upon the clinical side of things.
And we will add resources directly related to that because that payment is guaranteed. We're not guessing in terms of what we're going to get paid during that period of time. So they -- those 2 streams will influence what happens in sales and marketing. I think on the marketing side, we're still a couple of quarters away from stepping on the gas pedal where advertising will be a component of OpEx. That's probably more of a '25 event.
So modest increases for the next quarter or 2. The second half of the year, I think that you could start seeing some acceleration in the sales cost line. I think from a research and development or regulatory or clinical research standpoint, I think our level that we're presently at stays fairly flat for the next couple of quarters.
Okay. Great. Yes, that's super helpful. Maybe -- and then maybe one on Medicare, the technical assessment process. I guess you guys are expecting that after submission and that starts to take anywhere from 6 to 12 months. I don't know if you have like more narrow timing on that, just given your relationships, the meetings that you've already had with Medicare, but I guess just maybe some more color on that final approval day, their final reimbursement decision that you think?
Yes. Certainly, we're not in a position to make sort of any kind of hard prediction as to when that happens. I sort of mapped out how -- what the triggers are for us to request a pre-submission meeting. And then based on the results of that meeting, we'll be ready to submit the technical assessment immediately following the pre-submission meeting with MolDX and we intend that to be an in-personal meeting in Houston. So technically, the TA process is to turn around in 60 to 90 days. Now like FDA, anyone who's been involved in an FDA process, which since it's 90 days, there's an opportunity to stop that clock, right? They can stop the clock and ask for more information and so forth.
So it's a cumulative 60 to 90 days, that can stretch on for a period of time. But it's very hard to say, once that process starts, just like with an FDA submission, whether you sort of work through that 60 to 90-day window or as a result of inquiries along the way and pauses that stretches out beyond that. So really no way for us to predict at this point.
Your next question comes from the line of Anthony Vendetti from Maxim Group.
So I just want to -- so I know you switched to a new revenue cycle manager, I believe, mid last year and you're doing a much better job in terms of being able to get reimbursed. I think in the -- you've submitted approximately to commercial and government payers $20 million, and the vast majority has been adjudicated with half resulting -- nearly half in the allowed amount of $1,800 per test, which seems very, very positive and much better than what you were doing originally.
Does that mean if we -- and I guess the definition of vast majority, does that mean there's maybe $8 million maybe in revenue that you would expect in the pipeline, $8 million plus or how should we look at what's left to be adjudicated?
So your thesis is correct. So when you look at $20 million of submitted claims and the adjudication of 80%, 40% is an allowable amount, you're talking about $8 million or $9 million of possibility. That can be diminished by what the patient share of that will be. It also should reduced for what we have collected so far, which is nearly $2 million. There is a backlog of amounts awaiting for collection that could be as much as $9 million. I think looking at that in the range of $5 million to $6 million is probably more of a realistic view, but there's uncertainty about it.
So what gets paid of that, we've got this average that the information we're getting from Quadax puts the allowable amount right at $1,828 in the last quarter, which is holding. And I think the prior quarter was just slightly higher than that, maybe by $10 or $20 more. So it's in that range. But there's still some uncertainty about that, to try and figure out exactly what we're going to collect because of the patient's contribution and the timing related to when we'll get it.
Can I reemphasize that? I think the way we look at that $1,800 is pricing, right? So we feel like, okay, we're getting allowed claims about half the time and the price that they're sort of acknowledging, pricing in the vicinity of Medicare, which is great. Now if this is the high deductible patient, patient with a high deductible plan in January, that's -- the patient responsibility could be all of that. And so that's not necessarily what we're going to -- the proportion of that average $1,800 that gets converted into revenue is really highly uncertain at this point.
But what we're gratified by and what we're gratified in terms of the stability of is that pricing, the acknowledgment sort of that's an acceptable price, that's an allowed price which we can build our models around. But we still have time to see -- we still have to see where -- what the -- how much that allowed amount translates into payment. And it's not easy to track, right, because it's a stuff that's a bit out of phase.
Sure, sure. That's definitely helpful color. And then my last question is around your marketing efforts. I look at as a 3-pronged effort between the CheckYourFoodTube events that you've discussed, your Lucid test centers and then your satellite offices. As you move -- as we move through 2024 and go into 2025, how would you look at as best you can forecast the breakout on what's driving more patients?
That's great. I'll maybe tweak it a little bit just to focus on what is the patient acquisition strategy in those cases, right? So what you described is really sort of more of the cell collection location like how -- where we're actually doing the cell collection. And they're very much interrelated. And as you'll sort of know from my comment here that some of this is kind of starting to melt together.
But the patient acquisition around our sales force calling on physicians in various settings and getting them to order the test, that still represents a 70% or so of our activity. And of that, about 70% of that is being performed in the satellite test center model where our practitioners will show up at a physician's office on a regular schedule basis and do the testing there.
So think about the patient acquisition and sort of how is the cell collection stuff being handled. That's -- so that's that. About 1/3 of our volume right now is in these -- where the patient acquisition is centered around the CheckYourFoodTube event where we are engaged with the firehouse or now increasingly other types of entities where we schedule a health fair type of event and do the testing accordingly. It's not a result of a direct sales call by our sales folks, right? And there, the cell collection is in the CheckYourFoodTube setting. Now the third area, which I would encourage you to think of as a separate area that's now starting to kind of meld with the CheckYourFoodTube events is the direct contracting side. So when we engage with, let's say, an employer, that -- through a direct contract that -- the patient acquisition is done. That's the -- we have the contract, and there's a number of people who are indicated for testing based on guidelines, we based -- strictly on guidelines and we proceed to test them in a way that's very similar to the CheckYourFoodTube events.
We literally show up at their physical employer locations and test people at offer structure. So the patient acquisition side, it's direct contact with -- direct contact and engagement with physicians, a traditional sales process, looking for CheckYourFoodTube events through our engagement with fire departments and others and then its broader direct contracting pathway. Does that make sense? Again, slight difference between patient acquisition and the site and where the cell collection is actually kind of is sort of a matrix of actual collection.
Yes. No, Lishan, that's very helpful color. Just lastly, on the contracts with employers or commercial insurers. Is that -- would you still say that -- is that in the nascent stage? And is that something -- I know it takes sometimes a while because they each have their own processes. But is that something that you expect to accelerate as you move through this year and into 2025?
I think all of the -- answer to all is yes. So it's in the early stages. We hired our first person dedicated to this just in November. It seems like it's longer than that, but in November. And he's filled out the pipeline with regard to engagements with brokers, their part administrators, entities like the 9/11 Fund and the residential communities, that pipeline is filling up very fast.
So to the point where we actually are going to hire a second person to help him with that. But as Dennis mentioned, the cycles for these are longer than just converting an individual physician account, right? And so -- and to some degree, they can be a little bit lumpy around open enrollment periods twice a year, particularly those that are related to benefit packages, right, where you have to line up -- has to align with open enrollment.
So very busy. The pipeline is filling up, putting more resources into it, but it's longer lead times. But despite all that, we really do expect to start seeing some runs across the plate in the coming quarters, both in terms of test volume and revenue and contracts executed.
Your next question comes from the line of Mark Massaro from BTIG.
This is Vivian on for Mark. I'll actually maybe just keep it to one. So just as far as ASP, we've talked about a history of denials and appeals we needed to kind of lay the groundwork for commercial pay. Could you just reiterate some of your comments on the progress that you're seeing there? I think you also called out for the first time, prior auth being somewhat of a hurdle. So just how you're thinking about some of the puts and takes to ASP.
All right. So let me just jump in a bit on the process side and maybe Dennis has some additional comments. So the prior auth issue is simply one of when you look at the denials and the percentage, the breakdown Dennis mentioned, about 50% of those are informational or medical necessity. Those are -- there's an appeals process for that. But some about 18% are prior auth.
And remember, this has nothing to do with our -- it's not directly related to our efforts to impact medical policy, is through the out-of-network process. So we figured there are -- there's enough of a percentage on the denial, about 18%, that it was worth while to put a streamlined prior auth process together so that physicians can easily see the prior auth for what is typically a nonurgent test. So that's just simply a way to have access to the 18% of denials that are related to the lack of a prior authorization.
That's different than I think what the first part of your question was, I think, which is around the engagement with commercial payers on medical policy, which is something that's now starting to accelerate now that we have what we believe is sufficient CV and CU data to have those conversations. We just up until 3, 4 months ago, we didn't really have enough data to be legitimately involved in those conversations.
So as I mentioned earlier, we've actually started directly making inquiries and requests for changes in medical policy with some of the brand name larger payers with the hope that if it doesn't lead to an immediate change then we can engage in pilot programs and so forth. So I would see that as -- I would consider that as somewhat different than what we're doing on the prior auth side, which is really a revenue cycle management process. Dennis, did you want to add anything to that?
Yes. Just -- Vivian, just go back through the stats in case that's what you were looking at, 54% of those adjudicated were denied. And I gave some color on what half of them -- the reasons for half of them, and there were three buckets, right? 7% just needed additional information, 26% were deemed not medically necessary. And the question you asked about prior auth, authorization, was 18%. That said, they would like prior authorization before reviewing the claim. So it was a smaller portion of the total, but nonetheless, it is showing up as one of the reasons for initial denial.
Your next question comes from the line of Ed Wood from Ascendiant Capital.
On the high-volume CheckYourFoodTube type events, have you gone to any event more than once? And do you anticipate some of these events being annual events? Or what's your time period for going back to these events?
That's a great question, Ed. And yes, we definitely have gone back. Like, for example, the original San Antonio firefighter event that we did almost exactly a year ago, we went back and retested because the logistics, if you set up, let's say, 3 or 4 days, you're not going to necessarily get 100% of those who are interested in getting tested and are qualified or recommended for testing based on the risk factors. So we definitely have gone back. We even had ties where we've gone back and focused on retirees or different shifts and so forth. So that's -- we've done that.
What I may just again use this opportunity to emphasize, which is that one of the aspects of this that we're starting to push a lot harder on is as we get started to talk about how we can enter into a contractual arrangement for further testing after the inaugural event, so to your point, and we do see that as something that could be on a regular periodic basis. Certainly, some of the conversations we're having on the direct contracting side are -- would be periodic.
There are no further questions at this time. I would like to hand it over to Dr. Lishan Aklog for closing comments.
So thank you all for joining us today and for the great questions. I do actually have one additional comment that came from one of our investors that they asked the question of EsoCure because PAVmed released -- had a press release recently that indicated that it was reviving some projects, which included EsoCure.
And I just wanted to confirm and remind folks that EsoCure, which is an esophageal ablation technology that fits very nicely within the portfolio of products that's used to treat the later stage pre-cancers we discover with EsoGuard, that Lucid continues to have a fully exclusive license to commercialize that.
So although it's being revived at the PAVmed level, and PAVmed is seeking financing to complete its development, including some non-dilutive financing, Lucid remains the -- will be the commercial entity that commercializes it, if and when we're able to get that across the finish line.
So with that, as always, we look forward to keeping you abreast of our progress via news releases and periodic calls such as this one. And the best way to keep up with our news, updates and events is to sign up for e-mail alerts on the Lucid Investor Relations website and to follow us on Twitter, LinkedIn and on our website. So thank you, everybody, and have a great day.
Thank you, presenters. And ladies and gentlemen, this concludes today's conference call. Thank you for participating. You may now disconnect.