Automation Strategies for Molecular Diagnostic Market-Share Expansion

Automation is key to keeping operating costs in check as well as improving speed, consistency, and regulatory compliance by minimizing clerical staff decision-making that may be inconsistent or noncompliant. When automation is done correctly, it leads to increased cash collection and profit. Cash collection improvements between 20% and 40% and a reduction in turnaround time by 60% are achievable.

Automation can also extend to connectivity to referring entities to:

• Address missing or incorrect billing data
• Connect with patients if they need to adjust their insurance information
• Set up payment plans for out-of-pocket expenses

Eligibility and Benefits Verification Automation at the Plan Level

One of the most underrated processes in revenue cycle management is eligibility and benefits verification. Without effective verification, more than 50% of claims can be rejected because the patient is not eligible for the services rendered. Too often, eligibility verification is seen as a commodity, a simple “checking of the box” that the patient has coverage, but that is grossly oversimplified. Insurance eligibility and benefit verification can be tricky, especially with the increasing number of high-deductible plans, more frequent changes to a patient’s insurance plans, and a larger population of uninsured patients.

Molecular diagnostics laboratories need an eligibility-verification process that is automated and runs in real time to determine eligibility and benefits, coverage limitations, network status (i.e., in-network or out-of-network pricing), and patient out-of-pocket financial responsibility by going to the patient’s plan-level benefit verification. It needs to be an easy, efficient, and seamless process with clear, concise, current information.

These capabilities help keep the clinical workflow moving while ensuring the information required for reimbursement is correct and complete, including understanding any prior authorization requirements or medical necessity documentation. It enables more timely clean claim submission and expedites adjudication, which leads to fewer claim denials and faster cash collection. Having the right automated eligibility and benefits verification process in place improves the patient experience as well.

Automating Exception/Error Processing Improves Client Satisfaction and Speeds Reimbursement

Molecular diagnostics providers face daily challenges to maximize reimbursement from payors. Automation plays a vital role in speeding up the reimbursement process while driving down operating cost. Incorporating automation capabilities into revenue cycle management processes help maximize revenue reimbursement and workflow efficiencies, resulting in improved clean claim rates, improved cash collections, and profitability.

Many providers still rely on staff members to manage billing functions manually, but this opens up risks for typos and inconsistencies resulting in false claims. In addition, it is not the best use of resource for staff to review every encounter that comes through a billing system. Laboratories are better off using an exceptions-based approach that highlights billing errors in which patient billing information is invalid or missing. This way staff members are only reviewing the subset of claims that actually need attention. If a patient’s insurance subscriber ID number is invalid or missing, the revenue cycle management (RCM) system should be able to automatically send correspondence to the patient or physician, directing them to a patient or client portal and requesting their insurance subscriber ID number be updated, all without staff intervention. In this case, the error is resolved quickly, and as soon as the information is updated by the patient, the claim can be submitted to the payor.

To streamline denial management, XiFin recommends using configurable automation to map reason codes and remark codes to automate next steps. We recommend categorizing reason and remark codes and conducting a root cause analysis. It is important to determine if denials can be proactively prevented. The RCM system should also be able to map reason and remark codes to specific actions. For example, any claim with reason code CO4, which means the procedure code submitted is inconsistent with a modifier that was used, can be automatically assigned by the RCM system to a coder for review and resolution. Another example is a CO16 denial when a claim lacks information to be adjudicated properly. In most cases, the payor requires additional medical records to justify medical necessity. Once a request for additional information is made, the system can automate the process to gather this additional data. There are many instances where reviewing and mapping these codes can reduce and sometimes eliminate the need for staff to touch a claim.

Increase Appeal Success Rates with Automation

Molecular diagnostics providers are inundated with added requirements for prior authorization and medical necessity documentation. Unfortunately, payors do not always provide clear guidelines on requirements for reimbursement. As a result, appeals are one of the costliest revenue cycle processes. And they are a natural place for robust automation.

A common denial type is a “request for additional information”. Often, all that needs to happen to resolve these denials is for the laboratory to resubmit the claim with a copy of the report attached. This presents an opportunity to automate the process. In these instances, the RCM system can automatically access the report and the corresponding appeal letter, package it, and submit it. No staff intervention should be required to process these types of denials.

“Medical necessity” denials are more complex. There can be different appeal messages for different types of medical necessity denials. It is extremely valuable to respond to most appeals to maximize reimbursement, but it is also important to minimize the labor allocated to them. At XiFin, for example, when our outsourced services team receives a medical necessity denial, it is reviewed by a person to select the appeal letter that is the best choice for the particular denial. Then, the rest of the process is automated, and the appeal is tracked to resolution.

It is also common to see “payment amount disputes”. This is why it’s important to constantly evaluate contract allowable amounts and compare them against what a payor is allowing on claims. Laboratories must do the due diligence to ensure that claims are being reimbursed correctly and are not underpaid. In the XiFin outsourced billing service, for example, there are automated tools that do this as part of the payment posting protocols. These tools automatically flag claims so a user can immediately send out appeals for underpayments in batches or in bulk.

A Data-Driven Appeal Strategy Combined with an Automated Appeals Process Is Essential to Maximizing Reimbursement

Leveraging automation, reason code-specific logic and workflows can be configured to populate relevant data into proprietary appeal forms and payor-specific appeal letters, with supporting documentation attached. Using an RCM system with an automated appeals process capability coupled with a document storage technology can improve efficiency of appeals management, reducing cost and increasing reimbursement. Automating the appeals management process and incorporating payor-specific requirements improves appeal success rates and the speed of reimbursement. With molecular diagnostics laboratories seeing a continual increase in appeals, an automated appeals process is a necessity.

When researching comprehensive revenue cycle management solutions to optimize billing and accounts receivable, look for a solution that automates billing workflow and expedites the filing of clean and accurate claims. Effective automation can also go a long way toward dealing with denials or rejections, error correction, and speedy resubmittal. Learn more by downloading our whitepaper today.

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