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Outsourcing All or Some of the RCM Process Supports Compliance

The healthcare industry is notorious for nearly constant changes in laws, regulations, government, and payor requirements. It is difficult for an individual diagnostic provider to keep up with all the changes, particularly as it relates to compliance. Any compliance misstep can result in lost revenue, fines, and even extreme penalties like debarment, corporate integrity agreements, and criminal allegations against the company and responsible individuals. Commercial payor contracts can also have restrictions, and federal and state laws can restrict activities under insurance and other commercial relationships. 

Revenue Cycle Management (RCM) activities need to include thorough planning and monitoring to address potential compliance issues that can cost an organization money, business freedom, and even exit opportunities. Your organization needs an effective compliance program to act in accordance with applicable law and as a necessary risk management approach.

An individual healthcare provider may often lack the expertise in compliance. In addition, providers may also experience challenges maximizing reimbursement in the face of constantly changing payor edits. The main advantages of outsourcing all or part of the RCM process include:

Expertise – A dedicated outsourcing team that processes billions of dollars annually in gross claims for all types of providers, including hospital outreach, clinical, molecular, anatomic pathology, IDTF, and remote patient monitoring will provide the expertise your business needs.


Payor Relations – A focused team actively reviewing and managing the payor behavior across multiple clients provides insight not otherwise available and they can advocate based directly with payors and industry associations.


SaaS Based Technology – Your organization benefits from the innovations informed by many different diagnostic providers that use a cloud-based RCM solution provider that also offers outsourced billing services. Because they are heavy users and serve a variety of diagnostic and specialty physician providers, you can expect that the solution includes ongoing innovations to keep ahead of the industry. 


Flexibility – Outsourcing is a very economical way for organizations that have volatility in claim volume to operate. As volume changes, costs scale proportionately and are protected against contraction.

There is another compliance-related benefit to outsourcing the RCM process that can be difficult to address. When your employees manage the entire billing and RCM process, including decisions on coding, write-offs, and other billing matters, it inherently comes with the risk of fraud, waste, or abuse. Your compensation and management policies may also create unintentional incentives for bad or careless behavior. Outsourcing billing activities may help reduce the likelihood of these unintentional incentives and eliminate any inadvertent rewards or opportunities for such behavior. 

The separation of functions, whether managed in-house or outsourced, is an effective contributor to a successful compliance program. Separating functions also helps diagnostic providers to:

  • Maximize the use of electronic data transfer
  • Establish and follow RCM procedures
  • Monitor and audit RCM processes and transactions
  • Set a compensation program with no hidden risks built-in

These recommended practices may also help fulfill privacy and security requirements. Specifically, regarding compliance, an outsource RCM provider should be able to:

  • Ensure logic adheres to anti-mark-up regulations and stays current with ICD-10 and CPT codes, LCDs, NCDs, fee schedules, MUEs, NCCI edits, etc.
  • Handle complex claims including, differing dates or places of service, 72-hour or 14-day rules, TC/PC split billing, location considerations for institutional and professional claims, etc.
  • Manage consolidation rule logic to simplify payor billing rules and comply with payor medical policies and requirements.
  • Provide automation to avoid unnecessary manual intervention, which can lead to clerical decision errors.

Outsourcing all or a portion of your RCM activities to a highly rated team typically ensures that carefully developed business protocols will be followed as market or regulatory changes dictate. An outsourcing billing provider that also offers its own RCM solutions is better able to support the unique billing and reimbursement scenarios that diagnostic providers confront. Since they offer both an RCM platform and services, they can optimize billing and accounts receivable practices and can automatically identify and efficiently manage denials. Minimizing manual processes and clerical decision-making also reduces compliance risk.

Leading RCM software applications should have comprehensive compliance capabilities built in. Examples include compliance logic or flags within workflows, allowing audit trails, and having business continuity at its core.


With XIFIN, whether you choose to manage the RCM process in-house with XIFIN RPM or XIFIN's outsourcing services, you will have access to the same cloud-based technology and comprehensive RCM capabilities, including robust compliance features and resources.

Learn more about the value of outsourcing your revenue cycle management with XIFIN and contact us today.


Published by XIFIN
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