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Is Your Appeals Process Effective?

Over the last several years, the healthcare industry has undergone an enormous amount of scrutiny and restructuring. From the entrance of Affordable Care Act Health Plans to close examination of utilization trends and a significant increase in the patient burden related to the cost of healthcare, it has become increasingly challenging for healthcare providers to be paid for the services rendered. Health insurance companies are constantly looking for ways to decrease costs, which equates to an ever-changing landscape related to filing and reimbursement of insurance claims.

The increase in payor scrutiny, coupled with the increase in high deductible health plans and larger portions of the healthcare cost being shifted to the patient, has resulted in higher portions of compensation to which physicians are entitled being written off as bad debt. As this trend continues, it is increasingly important to ensure that follow up efforts by your billing team are effective and efficient to pursue the payments to which your practice is entitled.

The changes in the physician billing landscape have created a need for more appeals to obtain payment for medically-necessary services rendered. As an example, before a claim will be paid, payors are requiring medical records on a higher portion of anatomic pathology cases today than in the past.

It is important to keep in mind that when medical records are submitted, the entire record is reviewed, not just the piece related to the CPTs in question. Therefore, providers must ensure that their documentation supports all three criteria being scrutinized by the reviewer, for all procedures billed. Specifically, that each test/procedure was

  • Ordered
  • Performed
  • Medically necessary

Additionally, medical records are most likely being reviewed by a trained registered nurse (RN) who may or may not have experience in your specific specialty. For optimal outcomes on appeals, documentation provided for payor review should be written and presented in a way that can be easily evaluated for order, performance, and medical necessity by someone who may be medically trained, but without training in your discipline.

Through XIFIN’s revenue cycle management (RCM) solution XIFIN RPM,  many appeals with standard requirements can be automated to improve turnaround time and efficiency in processing for payment. Additionally, transparent reporting available in XIFIN RPM enables easy monitoring of appeals outcomes. This system functionality allows billing teams to spend more time focusing on high-dollar, complex appeals, such as those currently required for NGS and CDx testing, maximizing your collections.


Published by XIFIN
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