The Importance of Connectivity and Automation to Accelerate Revenue Cycle Management: A Focus on Insurance Eligibility and Discovery

Kouri Andrews
Director, EDI Operations, XIFIN

Mike Fauver
AVP Health Systems, XIFIN

Using disconnected systems to manage the complexity of medical claim billing and revenue cycle management (RCM) can lead to errors, inefficiencies, and rework. This drives delayed reimbursement and higher operating costs. It’s easy to think that “bolting-on” supplemental capabilities to a billing solution can fill any gaps or subpar RCM functionality, but the reality is that only a highly integrated RCM solution optimally streamlines the workflow to speed reimbursement, reduce denials, and decrease cost. 

Patient eligibility verification, for example, is a vital RCM function. There are plenty of bolt-on capabilities available for checking insurance plan coverage, but any mistakes or delays in accurately verifying eligibility will cause problems that impact the entire claim reimbursement. Insurance eligibility verification can be especially tricky with more patients participating in high deductible plans, frequent changes in insurance providers, and a growing number of uninsured patients.

Verifying patient coverage early in the RCM process is a critical step to help ensure claims are fully reimbursed. Automatically verifying patient insurance coverage before completing a test or submitting a claim results in fewer denials, improves the patient experience, and significantly increases staff effectiveness. Fortunately, there are automation tools available to make this a seamless, timely process.

Effective Code Translation: The Key to Accurate Eligibility Verification

Patient eligibility verification is about much more than a simple yes/no answer as to whether the patient’s insurance policy information is correct and current. The best eligibility verification solutions provide comprehensive, real-time eligibility screening that validates the patient’s insurance is active, identifies any secondary insurance for the patient, and gets to the plan level to confirm the co-pays, co-insurance, and deductible. 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. This complicates the verification process tremendously. Consider a payor that has 25 unique plans. Knowing that the payor data is correct does little to ensure coverage of a particular diagnostic test at a plan-level price. Obtaining accurate expected pricing is also important. It allows for more accurate patient responsibility estimation, which improves 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:

  • Fewer denials – Verifying insurance eligibility early in the RCM process reduces claim denials due to incomplete or incorrect patient eligibility information.
  • Less rework – Adding eligibility automation increases the efficiency and effectiveness of a billing team and streamlines workflows.
  • Shortened A/R days – Reducing denials and delays for rework accelerate the reimbursement process, reducing days sales outstanding (DSO), a key performance indicator, otherwise called accounts receivable (A/R) days.
  • Improved patient experience – Automating eligibility verification and conducting it in real time improves the accuracy of patient responsibility estimates and provides transparency, which improves the patient experience. This also increases the likelihood of patient payment for any balance due.

XIFIN RPM has a robust translation process for eligibility verification. It identifies and sets up translations and updates based on denial responses or alerts when new payor configuration is needed. It also leverages payor-level configurable rules for more accurate verification and expected pricing calculation. XIFIN RPM is designed to handle the translation of the complex messages returned by payors.

Integrated eligibility verification within XIFIN RPM also means that diagnostic providers don’t need to manage a separate clearinghouse, which reduces operating costs. For the few payors where XIFIN is not directly connected, if 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 customers.

Laboratories and other diagnostic providers need to identify coverage fast and reduce the number of claims being denied on the back end due to inactive insurance or non-coverage. Sometimes providing the most effective solution means partnering and integrating with industry-leading technology companies and service providers. If, for example, XIFIN RPM is unable to verify patient eligibility for a particular claim, the system is able to automatically connect to one of our fully integrated insurance discovery partners to identify any other policies associated with the patient.* Implementing automated insurance discovery early in the RCM process helps ensure fewer payment delays, less rework, and ultimately faster reimbursement.

XIFIN RPM also incorporates workflow and logic for specific CPT codes to have a prior authorization (PA) flag that drives exception or error processing workflow. XIFIN has preferred PA partners our customers can work with to 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 days or weeks. Plus, XIFIN RPM is designed to capture and transmit PA approval numbers, letters, and supporting documentation.

Having fully integrated, connected systems helps ensure that laboratories and other diagnostic providers maximize the speed and value of their reimbursements. Interested in seeing this workflow automation in action? Contact us.

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

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Published by XIFIN
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