The molecular diagnostics market has experienced tremendous growth in recent years. It’s a complex business with many challenges, including prior authorization requirements, diagnostic coding changes, the evolving regulatory landscape, and specimen collection moving from physician offices and laboratories to the home. Growing and scaling a successful molecular diagnostics business requires essential elements, including patient and physician engagement and revenue cycle management.
XIFIN recently published a new whitepaper, “The Executive’s Guide to Molecular Diagnostic Market-Share Expansion,” designed to provide molecular diagnostics leaders with critical success factors for maximizing revenue and growing market share. It includes practical approaches, process enhancements, and payor strategies essential to growing novel diagnostic market share through proactive, purposeful, and technologically enabled engagements with patients, physicians, and payors.
Over a series of blog posts, we’ll be highlighting several topics covered in this paper including:
- Physician engagement strategies and materials that educate on the availability of new molecular testing, applicability to their patient population and ordering guidelines.
- Physician office team approaches and technologies that maximize clean claims, automate denials, and execute payor-specific appeals strategies to maximize reimbursement.
- The value of purpose-built revenue cycle management solutions to increase cash collections and work in tandem with EHRs to facilitate physician adoption and efficient ordering of novel and esoteric testing.
- Effective patient communication touchpoints and technology enablers to support patients in preparing for out-of-pocket expenses and increase test completion rates.
- The specific types of business intelligence, data models, visualizations, and analytics that better inform molecular diagnostics executives, financial teams, and sales teams.
- Automation and process enhancement opportunities for prior authorizations, insurance discovery, benefits determination, eligibility verification, front-end payor edits, exception processing, and denials and appeals management.
This first blog in the series covers one of the foundational elements of successfully growing a molecular diagnostics business – establishing a comprehensive revenue cycle management (RCM) strategy. To thrive both operationally and financially, molecular diagnostics providers must develop and implement an RCM process that maximizes timely reimbursement. The core elements of an effective, strategic RCM process include:
Financial Integrity – one of the most important aspects of a sound RCM strategy, successful molecular diagnostics laboratories must have a financial foundation that delivers a complete financial accounting package that is both GAAP and SOX compliant and general-ledger ready. For those molecular diagnostic providers that are publicly traded or are considering going public, financial integrity is paramount, and a proper RCM solution with full referential integrity is a necessity.
Flexibility – or more precisely the right balance of rigor and flexibility is essential. Rigor is important so that making a change at one spot in the process does not cause a problem or inefficiency further along the workflow. Rigor is also crucial to ensuring regulatory compliance. Flexibility is key because payors are constantly changing the rules, and each payor has its own rules. The RCM system must provide for the ability to make granular (e.g., plan-level) changes that can then be applied more broadly (e.g., by client). The ability to make specific changes that can then be rolled across groupings makes it easier to keep up as the market environment changes.
Connectivity – gives laboratories the ability to leverage information that comes from different steps in the patient journey where it is needed in the RCM process. Systems need to be able to connect with others through real-time APIs. When information is corrected in one system, it needs to be shared automatically with other systems that need it.
Automated Workflow – designed to manage claims by exception is critical. A sound RCM strategy should seek to automate as much as possible to reduce clerical (one-off) decision-making and support compliant activities.
Business Intelligence and Advanced Analytics – molecular diagnostics providers must have effective business intelligence and advanced analytics tools to stay in step with changing payor behavior and address trends so that they can be harnessed or mitigated.
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The XIFIN whitepaper also provides a detailed blueprint for patient and physician engagement approaches designed to help molecular diagnostics laboratories grow revenue and profitability. The paper also covers the value of automating eligibility and benefits verification as well as the importance of providing timely, accurate patient responsibility estimation, and effectively managing prepayments.