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Connecting and Automating Diagnostic Revenue Cycle Management: Eligibility Verification Speeds Reimbursement, Drives Revenue, and Reduces Operating Cost

When laboratories and other diagnostic providers use multiple disconnected systems to manage the complexity of diagnostic claim billing and revenue cycle management (RCM), this often leads to errors, rework, and other inefficiencies, ultimately driving higher operating costs. Diagnostic providers sometimes attempt to connect or “bolt-on” supplemental capabilities to augment missing or subpar RCM functions in their primary billing solution. For example, eligibility verification is a central RCM function and should be at the core of RCM solutions. Otherwise, any mistakes or roadblocks to quickly verifying eligibility causes unnecessary delays. Only a highly-integrated RCM solution optimally streamlines the workflow to speed reimbursement, reduce denials, and lower cost. 

Insurance eligibility verification can be tricky, especially with the current trends toward patients taking on more payment responsibility, more frequently changing insurance providers, and a larger group of uninsured patients. Verifying patient insurance eligibility early in the revenue cycle management (RCM) process is a critical step to ensure diagnostic claims are fully reimbursed. Laboratories and other diagnostic services providers that automatically verify patient insurance coverage prior to completing a test or submitting a claim achieve fewer denials, improve the patient experience, and increase staff effectiveness. There are new automation tools to make this a seamless, touchless process.

Accurate Code Translation: The Key to Success

Eligibility verification is much more than a binary yes/no regarding whether the patient’s insurance policy information is current. A thorough, real-time eligibility screen can validate that the patient’s insurance is active, identify whether any secondary insurance exists for the patient, and confirm the co-pays, co-insurance, and deductible from the insurance provider. One of the most challenging components of automating eligibility verification is translating the various codes used by different payors in the verification process. Many payors have dozens of plans with different pricing for the same diagnostic test complicating this translation process.

XIFIN has a mechanism to identify and set up translations in the XIFIN RPM solution and proactively update the system based on denial responses or via alerts to the users regarding a new payor configuration needed. The robust translation process also leverages payor-level configurable business rules, thereby supporting more accurate verification and expected pricing calculations. For example, consider a payor that has 20 different unique plans. If the order entry process only captures that payor and not the specific plan, a simple yes or no that the provided payor is correct does little to ensure coverage of a particular diagnostic at a plan-level price. The XIFIN RPM platform allows for the translation to be set up in a number of ways and designed to handle the complexity of the message returned by the insurance providers. Obtaining accurate expect pricing allows for more accurate patient responsibility estimation, thereby improving the patient and client experience. It also allows for more precise financial management with accurate revenue recognition.

The benefits of an effective, automated eligibility process include:

  • Decreased claim rejections and denials – Verifying insurance coverage upstream in the RCM process increases reimbursements and reduce denied claims due to inaccurate or incomplete information.
  • Reduced manual rework – Adding eligibility automation increases the efficiency and effectiveness of a billing team and streamlines workflows.
  • Shortened A/R days – Reducing denials positively affects the days sales outstanding (DSO) key performance indicator, otherwise called accounts receivable (A/R) days. Expediting clean claims submission grows revenue because XIFIN research finds that many denials are never resubmitted.
  • Improved patient experience – Automating real-time eligibility verification helps to accurately estimate patient responsibility amounts, delivering transparency, and increasing the likelihood of patient payments for any balance due.

Clearinghouses, Insurance Discovery, and Prior Authorization

XIFIN continually strives to bring its clients the most innovative and practical solutions to their business problems. Clearinghouses are another entity that diagnostic providers must interface with, and those associated expenses must be considered in the total cost of billing. Integrated eligibility verification within XIFIN RPM means that diagnostic providers don’t need to manage a separate clearinghouse. For the few payors where XIFIN is not directly connected, and it is not mutually economical to have a direct connection established, clearinghouses are used. But in this case, XIFIN manages the details, thereby reducing complexity and costs for our clients.

Critical elements of providing the most effective solution means partnering with industry-leading technology companies and service providers and ensuring their capabilities interface, integrate, and seamlessly interoperate with the revenue cycle management workflow and data exchange. For example, suppose the XIFIN RPM solution is unable to verify eligibility, in that case, the platform automatically connects to one of two integrated insurance discovery partners to identify any other policies associated with the patient.* With the increased cost of healthcare to patients and the complexities of insurance eligibility verification, including more uninsured patients, laboratories and other diagnostic providers need to identify coverage fast and reduce the number of claims being denied on the backend due to inactive insurance or non-coverage. Implementing automated insurance discovery early in the RCM process helps ensure fewer payment delays, less rework, and ultimately faster reimbursement.

Regarding prior authorizations (PA), The XIFIN RPM workflow and logic also allow specific CPT to have a PA flag that drives exception or error processing workflow. XIFIN clients can also work with XIFIN’s preferred PA partners. They can identify whether a PA is required for the specific diagnostic with a payor if that is unknown. By having purpose-built PA capabilities interface with XIFIN RPM, diagnostic providers get a simplified process, data, and document exchange resulting in PA approvals in a matter of hours, not numerous days or weeks. Plus, XIFIN RPM is designed to capture and transmit PA approval numbers, letters, and supporting documentation.

Interested in seeing this workflow automation in action? Contact us.

*only available for clients who have contracted with the insurance discovery partner.


Published by XIFIN
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