Optimizing Billing and Cash Collection—Valuable Lessons Specialty Providers Can Learn from Clinical Laboratories

  • Sr. Director, Genetics and Novel Technologies, XiFin

In our work at XiFin, we support a wide variety of medical providers, many of whom share similar challenges. While our founders and initial clients come from the laboratory space, we see an expanding need for flexible revenue cycle technology and services in other specialty and ancillary spaces.   

Specialty providers like radiologists, pathologists, anesthesiologists, remote patient monitoring and medical device companies tend to have additional challenges being reimbursed for the critical work they do because they are less directly connected to the patient prior to services being performed. These providers increasingly face complex and changing reimbursement requirements from over 3,000 US payor plans, especially for new and innovative services. Even home health providers have a high bar when it comes to proving appropriateness of their products and services.  

We frequently hear that these physicians and providers feel like they are on the outside looking in when it comes to keeping up with the complexity and obtaining the correct patient information needed for reimbursement.   

Limited Patient Access 

Often these providers do not have access to the clinical systems/EMRs/EHRs of their referring entities. They may get some patient demographic and diagnostics information, but it is generally limited and frequently out of date. The indirect nature of how labs and other ancillary providers serve their patients can lead to an inability to effectively bill insurance companies for the services/products provided, and often “surprise” bills where consumers receive bills weeks, or even months, after the office visit. 

The lack of direct access to the patient, and often the referring physician or entity, at the time of the service/product order results in a larger than average percentage of challenges from insurance companies related to incorrect coverage information and lack of medical necessity. Ultimately, this leads to sub-optimal payment for services rendered. 

Unique Reimbursement Challenges 

Laboratories have dealt with these same reimbursement barriers over the years, especially when it comes to developing new and complex tests. In response, sophisticated labs have developed a strategic approach where they leverage their billing system, known as a revenue cycle management (RCM) system, to maximize efficiencies and improve cash collection. Specialty providers can learn from labs and leverage these same approaches and billing solutions to their advantage. 

There are many similarities between the revenue cycle and reimbursement challenges encountered by clinical laboratories and those issues faced by ancillary medical providers. Margins for lab services, specialty physician services, and home health products continue to be compressed, thus, optimizing claim reimbursement is critical to financial success.  

  • Indirect relationships with patients

  • Ongoing fee compression

  • Limited coverage criteria

  • Complex and changing payor-specific rules

The most notable of these challenges, which can result in increased denials and negatively impact reimbursement, are shown on the right.

Technology Limitations 

The skilled treatment from ancillary providers improves overall outcomes, yet these providers are often left out in the cold when it comes to obtaining and organizing the information they need to bill appropriately for their services and products. Fierce Healthcare points to technology as one of the main challenges for these providers: 

"The absence of interoperability in the systems used by ancillary providers for capturing, coding, and billing patient care. The systems for billing and communication with providers and payors are particularly disjointed. This is critically important if care is going to shift from the individual patient to a population health model. Coordination of care, utilization management, and patient satisfaction may all hinge on the ability of providers—ancillary providers included—to access the same information regardless of where patients go for their care."

The lack of proper data integration creates a barrier for specialty and home health service providers. This is in line with the historical issues faced by laboratories, particularly in the area of precision testing where detailing information on the patient’s history, diagnosis, and additional clinical documentation are required by the payors to prove the appropriateness of the service.  

Unless a provider has a highly automated and effective process for collecting specialty claims, it’s simply too complex and expensive to appeal a denied or improperly paid claim. Eventually, these claims get written off, or the patient’s share of the cost increases unnecessarily. This creates a bad patient and referring physician experience and an overall difficult business model for ancillary, remote, and specialty providers.  

An Experienced RCM Partner 

While many non-traditional providers understand the challenges inherent in their process dealing with new CPT codes, modifications in payor rules, additional documentation requirements, fee schedules, and industry-specific regulations, it isn’t generally the core competency of these practices. Nor is it where they want to be spending their time and effort. This situation is identical for clinical laboratories.  

Specialty, remote, and home health providers need an RCM partner that provides the necessary system and expertise to handle stringent coverage criteria and requirements by service and payor plan. The ability to leverage electronic information via interoperability, APIs, and robust configurable edits is why the country's most successful clinical laboratories choose XiFin. This is also why more specialty, home health, and ancillary providers are choosing XiFin as well.  

An experienced RCM partner is critical to the strategy of the provider in helping ensure that they are reimbursed for their services and products. For example, at XiFin we help our pathology, radiology, remote patient monitoring, DME, and medical device clients by streamlining the front-end editing process before submission and appeals process. The XiFin technology and collective intelligence allows our team of payor policy experts to continually update the RCM platform with payor requirements and leverage metrics on individual payors to improve both first-pass submission and appeals success significantly. Reducing the resource-related costs of addressing missing information on the front end as well as those associated with performing an appeal, and strategically targeting the process, helps reduce the denial rate and improve appeals outcomes.  

XiFin Is Your Partner for Specialty Provider Billing and Revenue Cycle Management 

The XiFin system delivers the intelligent workflow automation, real-time connectivity, and financial integrity you need to take control of pricing and reimbursement. Not only does XiFin remove reimbursement obstacles, but it also gives you the tools you need to maximize efficiency and cash collection. 

If managing the complexities of the revenue cycle and reimbursement for your practice isn’t part of your core focus, you may choose to outsource the entire revenue cycle management process to XiFin. Should you decide to transition part or all of the process in-house at some point, it’s an easy transition. 

Whether you choose XiFin’s in-house or outsourced partnership model for your billing or revenue cycle management, you get a proven, highly-automated cloud-based solution for workflow automation, financial management, and regulatory compliance. Its automated workflow is designed to help your company maximize claim reimbursement for every service or product. Other billing systems leave money on the table from underpaid claims and higher labor costs. XiFin delivers 100% reconciliation, identifying the source of any revenue shortfalls. You get the visibility you need to pursue and appeal any denied or underpaid claims, with minimal staff intervention. 

XiFin drives increased revenue and collections while improving operational efficiency by eliminating clerical decision-making. Start increasing your cash collection rate while gaining the visibility you need to optimize your financial performance. 

Learn more about XiFin RPM 15 and take the first step toward getting more of what you need in your revenue cycle management solution.

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Published by XiFin
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