Unlocking Market Access: How One Molecular Diagnostics Laboratory Transformed Reimbursement with RCM Data Insights

Market access is a cornerstone for healthcare providers striving to achieve widespread adoption of their tests and services. A market access team is tasked with securing consistent coverage across payors, negotiating contracts, and ensuring reimbursement aligns with the value of their diagnostic services.

Growing complexities in billing processes and payor policies create significant challenges for market access teams. They must navigate a labyrinth of payor requirements and evolving policies and behavior. For these reasons, a robust market access strategy and a reliable revenue cycle management (RCM) partner are essential.

For one molecular diagnostics laboratory, these challenges were creating a real impact. High denial rates, unclear coverage policies, and a growing disconnect between expected and actual payments threatened growth and financial stability. With the right RCM partner and data-driven strategy, the lab overcame these obstacles and transformed them into leverage for broader coverage and stronger financial performance.

The Challenge: Gaps in Coverage and Lost Revenue

Despite its highly specialized genetic testing capabilities, the lab faced recurring market access and RCM-related hurdles:

• Investigational/experimental classifications led to high denial rates and inconsistent reimbursement
• Timely filing denials were frequent due to the extended processing time required for complex tests
• Unpublished Medicaid policies created ambiguity and made reimbursement planning nearly impossible
• Payment discrepancies between expected and actual reimbursement amounts were underreported, increasing audit risk and leaving revenue uncollected

These issues weren’t just frustrating; they were costly.

The Turning Point: A Data-Driven Partnership

The lab turned to XiFin to help uncover the root causes of these problems and create a path toward improvement. With real-time access to RCM data and a collaborative partnership model, XiFin empowered the lab’s market access team to make smarter, faster decisions.

Together, they:

• Identified and addressed denial trends using robust analytical tools, enabling the lab to appeal claims and reduce rejections proactively
• Secured reconsideration for a local coverage determination (LCD), using XiFin data to demonstrate clinical value and drive reimbursement clarity
• Negotiated an extension to the timely filing window with a national payor after demonstrating that existing limits didn’t account for the lab’s processing times for complex genetic testing
• Recovered underpayments by leveraging XiFin’s discrepancy reporting, including one instance of over $2 million in unreimbursed revenue
• Aligned cross-functional teams through monthly meetings between market access, the commercial team (i.e., sales and client service), RCM, and finance—resulting in faster resolutions and better strategy coordination

This operational visibility gave the market access team the insights and evidence to develop payor-specific strategies, negotiate confidently, and effectively advocate for expanded coverage.

Understanding Payor Behavior: A Competitive Advantage

One of the most transformative outcomes of this partnership was the lab’s ability to anticipate—rather than react to—changes in payor behavior. Using XiFin’s business intelligence capability, the lab was able to:

• Pinpoint root causes of denials, such as incorrect codes or mismatches with policy requirements
• Adapt quickly to policy changes, including updates to Medicare LCDs and commercial payor rules
• Leverage ordering and reimbursement trends to strengthen their case during contract negotiations

Results: Measurable Impact on Revenue and Coverage

The lab’s collaboration with XiFin produced a wide range of positive results, including:

• Denials dropped significantly as proactive appeals and updated policies led to cleaner claims
• Contract negotiations were more successful, thanks to utilization data and financial insights
• Underpayments were recovered, ensuring the lab received what it was owed for services already rendered
• Audit risks were reduced through greater transparency and better documentation
• Coverage expanded as the market access team presented strong, data-backed arguments to payors

Key Lessons for Other Providers

This lab’s experience offers important takeaways for other healthcare organizations seeking to improve their market access performance:

• Treat data as a currency: Real-time RCM data and denial trend tracking are essential for building your market access strategy, navigating policy complexity and justifying reimbursement
• Cross-team collaboration amplifies success: Regular touchpoints between market access, the commercial team, finance, and the RCM team prevent silos and speed up issue resolution
• Proactivity pays off: Intervening early with data-backed insights leads to better outcomes—before issues escalate
• Trends are levers of influence: Payors respond to evidence; utilization patterns, prior authorization data, and reimbursement outcomes all help strengthen your position
• Stay compliant and audit-ready: Monitoring discrepancies and tracking policy changes minimizes risk and keeps you prepared

Market access success is about making the right case with the right data at the right time. By partnering with XiFin and embracing a data-first approach, this molecular diagnostics lab turned reimbursement uncertainty into a strategic advantage—resulting in expanded coverage, improved financial outcomes, and greater patient access to life-changing diagnostic services.

Want to see how these market access strategies could apply to your organization?
Download and read the full Customer Success Story, or
request a session with our Market Access expert, Clarisa Blattner, Senior Director of Payor Optimization.