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XIFIN’s Data Assists in Discovery of Standards Violation

  • Senior Director of Software Engineering, XIFIN

With more than 3,000 payors, a siloed provider will not have the breadth and depth of data to determine if payors are adhering to standards. Because of the high volume of claims XIFIN processes and the managed services that are offered as part of our XIFIN RPM solution, our EDI services team has visibility across these payors for all of our clients. As the provider of a cloud-based revenue cycle management solution that handles in excess of $40 billion in gross annual claims, XIFIN has a wealth of data that spans a wide spectrum of use cases from both institutional (i.e., hospitals, health care facilities, etc.) and professional (i.e., doctor’s offices, laboratories, etc.) health care provider organizations.  

As an example of the power of this data, earlier this year XIFIN leveraged the rich data captured from payors via standard ERAs in the X12 835 format to identify widespread misuse of the CO-45 Remittance Advice Reason Code (RARC), spanning multiple years. Per current specification, an adjustment reflected on a CO-45 or PR-45 cannot equal the total service or claim charge amount for the submitted claim. The verbiage below can be found here.

XIFIN analyzed data from across our customer base and identified the top 30 payors that have the highest occurrences of CO/PR 45 misuse that are in direct violation of the standard. In this specific situation, misuse is defined as the use case where payors or ERA providers are using the CO/PR-45 to handle full denials or non-payment of claims instead of using a more applicable denial or reason codes for situations like non-covered services, procedure code bundling, etc.

In this misuse scenario, many billing systems and/or providers are likely to improperly bill the patient or write-off the claims based on the application of wrong reason code to the service line. 

XIFIN contacted the identified payors and is currently partnering with them to provide remediations on their systems to address the misuse. Several payors have already corrected these issues in the first half of 2019, while many others are implementing corrective action plans with target dates in the second half of 2019. 
Remediation steps and plans are also being facilitated with the help of and CAQH Core as industry partners to XIFIN in ensuring continued advocacy for standards compliance. WEDI ERA/EFT workgroup team members discussed in the recent X12 workgroup meetings the importance of RARC codes and recommended a cross-walk review.

This scenario underscores how important it is to pay attention to your data. It also points out how important it is to have a partner like XIFIN who offers managed services. Without a rich database like XIFIN’s, it is very difficult to identify issues like this one that cross payors and affect multiple laboratories, nor to have enough critical mass to engage payors and effect change.

Published by XIFIN
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