The appeals process is one place that many labs and diagnostics providers can improve automation, efficiency, and reimbursement. With XIFIN, labs gain an additional advantage through the collective intelligence gained from across the hundreds of thousands of appeals submitted each year by our clients.
There are plenty of reasons that a claim can be denied. Some of the most common reasons are:
- No out-of-network benefits
- No prior authorization
- Experimental or investigational treatment
- Not medically necessary
- Not a covered benefit
The appeals process is typically initiated by a finalized, adjudicated claim denial from the insurance payor. Organizations that use XIFIN RPM find that it is easy and effective to appeal a segment of these denials to increase reimbursements.
Within XIFIN RPM, it's simple to set up appeal letters that correspond to the common denial reasons. The system also supports the proprietary appeal forms some insurance companies require and those Medicare requires (e.g., a redetermination form for first level appeal and a reconsideration request for a second level). Labs can develop an unlimited number of appeal letter formats.
With XIFIN RPM medical cycle billing, lab billing personnel can generate a single appeal with a just a few clicks, or easier yet, search for a specific combination of payor and reason/denial code and generate appeals in bulk across all qualifying claims. The system also provides document management capabilities that let users upload and link supporting documentation needed in the appeals workflow. This document management functionality can be extended to the ordering physician via a client portal to securely upload and link supporting documents like medical records to an appeal. The system automatically delivers appeals packets directly to payors that accept faxes, or sends them to a statement vendor for mailing appeal packets to the payors.
Once appeals have been submitted, it's important to measure the outcome. XIFIN RPM provides dashboard reports to quickly see the number of appeals outstanding in the system as well as the average payment of processed appeals. In addition, the lab can run detailed reports to enable the tracking and success rate of for example specific payor/denial combinations. These reports not only help the labs track their appeals, but also allow them to gain an understanding of what appeal letters are working under which scenarios for certain payors.
XIFIN customers perform more than one million appeals annually. In the first half of 2017, more than 1,000 types of appeals were submitted to more than 2,200 payor plans. These appeals resulted in more than $60 million in additional insurance payments. XIFIN is able to analyze data across our clients to help us further understand what works, or doesn't, in the appeals process. This collective intelligence allows us to understand the successful appeal packets for different appeal scenarios. We pass this knowledge on to our clients to help them understand which payors are paying appeals and which types of appeals are most successful. Clients can use this data to prioritize appeals and forecast additional reimbursements. For example, we have found that including medical records with appeals increases the likelihood of coverage by 60%.