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Selecting a Purpose-Built Lab RCM and Service Is the Right First Step ― But They’re Not All Equal

  • AVP of Strategic Revenue Operations , XIFIN

Over the past year, leading global IT research and advisory firm, International Data Corporation (IDC) published a paper and participated in a webinar discussing the benefits for hospitals and health system laboratories in choosing purpose-built revenue cycle management (RCM) systems. In the IDC paper, research director Mutaz Shegewi examines the specific benefits for hospitals and health systems that should be considered when selecting a purpose-built laboratory RCM capabilities, including:

  • Increasing the ability to collect on claims regardless of volume, value, or complexity while minimizing labor costs.
  • Improving reimbursements through fewer denials and improved appeals success.
  • Minimizing labor costs through robust workflow automation, configuration, and logic specialization.
  • Enhancing financial visibility with AI–enabled business analytics and visualizations.
  • Facilitating delivery of lab-specific business intelligence to enable data-driven decision making.
  • Improving bidirectional data exchange that helps close gaps in care and drives better outcomes.
  • Mitigating risk and compliance exposure by minimizing clerical decision-making through workflow automation.

Shegewi makes a clear and persuasive case for hospitals and health systems to enhance their operating models by adding purpose-built laboratory RCM capabilities. Once an organization validates the advantages of this approach, its team must still select the right technology vendor to best support these outpatient and ancillary services laboratories.

Some of the key differentiating capabilities to consider in selecting the right RCM system and business process outsourcing partner for hospital and health system ancillary services include:

Client Portal

Missing information required for reimbursement is the number one issue for many labs have. XIFIN RPM, for example, reduces the average time it takes to resolve missing information from approximately 60 days to about 20 days. Through the Client Portal, physicians can also perform order entry, access clinical decision support, examine statements at the line item level, and view test information and pricing.

Patient Eligibility

The XIFIN RPM patient service center (PSC) lets labs check test information and screen for patient eligibility upfront. Labs gain access to eligibility information in real time, including coverage, eligibility, deductibles remaining, and out-of-pocket or annual maximums reducing administrative time spent on hold and faxing insurance payors to gather this data.

Patient Responsibility Estimator

The PSC and Client portal also provides a sophisticated patient responsibility estimator that unlike other patient responsibility estimators on the market leverages all of the data required to more accurately calculate the forecast of patient responsibility. XIFIN RPM therefore creates a much more precise patient responsibility estimate. By providing patients with real-time estimates of their portion due, labs vastly increase the potential for collecting at or before the time of service. The web address for the patient responsibility estimator can be embedded into a diagnostic provider’s website, making it even easier for patients.

Prior Authorization (PA)

PA requirements create a time-intensive burden that delays patient care and takes providers and staff away from their clinical activities to spend that time with administrative tasks and redundant paperwork. Through XIFIN strategic partnerships the PA process is streamlined and integrated. With AI-driven technology, treatment plans can be assessed for individual payor PA requirements, submitted electronically, and monitored for approval or follow-up automatically. Approvals are then routed to the scheduling department in real-time and, if it’s determined that follow-up or exception handling is required, the PA can be still be processed without interfering with staff workflow.

Appeals Automation

One of the most labor-intensive parts of the claims process is denials and appeals management. With XIFIN RPM, much of the denials and appeals management process can be automated, including the attachment of additional documentation (e.g., medical necessity, prior authorizations) and generation of appeal letters. Only the most complicated claims are left to be handled by exception, which ultimately reduces the total cost of billing. XIFIN RPM can also automate the generation of appeal letters based on an American National Standards Institute (ANSI) denial code and can attach patient requisitions and lab results if the lab chooses to integrate those.

For clients who choose to outsource their billing to XIFIN, we select the top ANSI denial codes each month and review which payors are sending them and what can we do to get the lab paid. For example, we may see a bundling denial that means we need to write consolidation logic to append a modifier to tell the payor it’s a distinct procedure.

Monthly Financial Review

Conducting a monthly financial review with each of our outsource RCM clients on trends in their business provides enormous value. We interpret all of the data available so that each client knows what to focus on to improve business results. The analytics supplied through XIFIN RPM are as important as the billing and reimbursement process itself. We also assist the client in evaluating their profitability by reviewing their payor mix and denial trends. For example, if we find a client is losing money on a particular test, we will present that data to the payor and have our payor relations team renegotiate the pricing on this test.

Electronic Data Exchange

Direct connection to payors enables us to get claims in the door days faster and get a much better view of eligibility. We route claims to clearinghouses only when necessary.

The XIFIN team has developed collective intelligence in revenue cycle management that we use to add valuable capabilities to our RCM solutions and provide indispensable services to our laboratory clients. One of our goals is to automate as much of the RCM process as feasible and having our clients manage as little paper as possible, since paper inherently comes with risks of error and compliance violations.

As Shegewi states in the Parting Thoughts at the end of the paper, “Laboratory RCM requires a high degree of specialized expertise.” He also recommends that hospitals and health systems “Seek a vendor that offers an end-to-end RCM solution with managed services and a track record of success with the specific challenges and industry changes that impact your lab.”

We hope the information above is helpful and hope that you consider XIFIN in your decision-making process. In the meantime read what some of our clients have to say.


To learn more about the details of the IDC analysis and findings, including the considerations that lead to suboptimal laboratory financial performance and risk exposure, read the IDC white paper, "Making a Case for Purpose-Built RCM: How Actionable Data and Lab Visibility Benefits Health Systems." 

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Published by XIFIN
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