Automating the Patient Experience at the Time of Genetic Test Order

Genomic and molecular tests are famously complex and present many unique operational and financial challenges for laboratories. Here, we focus on strategies to improve the patient experience and better ensure reimbursement such as:

• Maximizing artificial intelligence (AI)-enabled analytics to keep up with ever-changing payor policies and requirements
• Enhancing physician engagement to help increase ordering volumes, maximize clean claims and automate denials and appeals management
• Novel ways to engage genetic counselors to better anticipate and respond to payor behavior
• Programs that leverage genetic counselors to have greater confidence and predictability of reimbursement success at a payor/plan and test level
• Effective patient communication enablers to assist patients in preparing for out-of-pocket expenses and increase test completion rates
• Intelligent automation of prior authorizations, insurance discovery, and benefits determination

Physician Engagement Programs

Physician engagement programs help diagnostic providers more deeply integrate communication and data exchange with ordering physicians. Physician engagement technology, including electronic communication tools, such as portals, help physicians and their teams streamline the correction of missing information and errors online, which improves satisfaction, speeds reimbursement, and provides cost savings.

With effective physician engagement programs and technology tools, physicians and their staff can more effectively:

• Perform order entry
• Access clinical decision support
• Examine statements at the line-item level
• View test information and pricing
• Correct billing errors upfront to expedite reimbursement
• Provide patients with an estimate of their out-of-pocket costs

XiFin-recommended practices for physician engagement include physician welcome letters. Welcome letters facilitate future reimbursement by setting expectations with physicians up front. We recommend that these welcome letters review test menus and payor policies for top payors, which can be used to create guidelines for ordering physicians regarding requirements to achieve prior authorization and the documentation needed to accompany each test specimen. Addressing requirements proactively improves the likelihood of reimbursement and strengthens appeal success.

Patient Engagement Tools

Effective physician engagement programs also address the value of patient engagement technology tools. Patient engagement technology helps diagnostic providers offer self-service tools that enable patients to securely log in, anytime, to:

• View statements
• Make credit card payments
• Set up payment plans (using lab-specified rules and parameters)
• Establish paperless billing
• View patient responsibility estimates
• View test results

Patient engagement tools provide a variety of benefits, including offering a cost-effective alternative to traditional customer service calls and supporting patients’ communication preferences.

Patient Financial Responsibility Estimation

Another important aspect of patient engagement that plays a crucial role in helping to ensure full reimbursement for diagnostic testing is the ability to provide patients with an accurate estimate of their out-of-pocket costs associated with a test. Accurate patient payment estimates are proven to reduce write-offs.

To provide an accurate assessment of a patient’s financial responsibility, the estimation tool must consider relevant provider-specific pricing information and test or procedure information, as well as provide access to real-time eligibility data. It is also predicated on receiving complete and accurate information back from the payor. Examining payor behavior can uncover responses that create inaccurate patient responsibility estimates.

Monitoring Payor Behavior

Payor reimbursement behavior is complicated and constantly changing. It is common for diagnostic providers to only learn about a change in reimbursement after month-end close. These changes manifest in billing as:

• New denials
• Changes in denial rate
• Change in reimbursement rate
• Change in time to payment

Failure to quickly recognize and adapt workflow to payor reimbursement changes can result in costly appeals and write-offs. XiFin recommends that providers adopt a proactive strategy to identify changes in reimbursement earlier. It’s important to understand the impacts and risks of expect price discrepancies and changes in pricing to patients.

Improving Prior Authorization (PA) Success

Many laboratories struggle with getting prior authorizations approved, particularly for new and novel genetic tests. XiFin has found that genetic counselors can play a vital role in navigating the patient experience and working with payors to get tests approved. We developed a new process and invested in personnel that brings together payor intelligence and clinical expertise to dramatically improve prior authorization approval success rates for genetic tests.

This new process involves a deep dive into payor policies for each test in a laboratory’s test menu. Genetic counselors craft questionnaires based on the derived payor intelligence to drive requirements for prior authorizations and streamline the PA approval process. This use of genetic counselors has been found to assist our laboratory customers proactively with both market access and revenue cycle management.

We’ve created a new team approach to PA medical necessity review, with four specific roles on the team:

Coding team: Focuses on front-line medical necessity review.
Genetic counselors: Payor outreach.
Outbound team: Patient outreach.
PA team: Oversees and executes the PA process.

We tested this new approach on approximately seven hundred tests with a national laboratory for two months, earlier this year. The new team conducted screenings, tabulated results, and submitted prior authorizations with the requisite forms and clinical documentation. The team monitored results from the payors and compared them against the indication/probability of approval based on the completed screening.

Analytics-Informed Workflow Adjustments

Finally, we recommend that diagnostic organizations use analytics to drive early insight into changes in payor behavior and address changes in ordering patterns and client data quality. Address root causes, adjusting workflow as needed to eliminate errors and automate appeals. Be sure to choose an RCM platform, like XiFin RPM, that supports AI to drive efficient automation of workflow adaptation to payor changes.

Learn more about how XiFin helps molecular diagnostics laboratories maximize reimbursement and automate the patient experience for genetic tests at the time of order.