Breaking Barriers: Overcoming Coverage and Reimbursement Challenges with RCM Support (Part 3 of 3)

Securing payor coverage and reimbursement remains one of the biggest challenges facing healthcare providers today. Navigating the maze of medical policies, coding requirements, and contract negotiations requires expertise and collaboration. With the right revenue cycle management (RCM) partner, healthcare providers can overcome these hurdles and unlock new growth opportunities.

Key Coverage Challenges

1. Medical Policy Compliance: Ensuring tests meet clinical utility standards.
2. Coding Accuracy: Using the correct CPT^® codes to avoid denials.
3. Contract Negotiations: Aligning with payor requirements while advocating for fair reimbursement rates.
4. Prior Authorization: Managing increasing demands for documentation

Failure to address these challenges can lead to denials, increased operational costs, and strained payor relationships.

How RCM Partners Support Coverage Expansion

The right RCM partner provides the expertise and tools needed to:

• Align with Payor Policies: Conduct medical policy analyses to ensure compliance.
• Enhance Coding Accuracy: Reduce errors and streamline the reimbursement process.
• Optimize Contract Terms: Leverage data-driven strategies to negotiate favorable agreements.

For example, RCM partners can help justify the removal of prior authorization requirements or guide providers through the LCD reconsideration process. These efforts improve reimbursement rates and expand patient access to diagnostics.

RCM partners with robust cross-customer data and deep domain expertise can also support providers with:

• Market analysis

  • Reimbursement trends across a cohort of providers offering similar services and testing
  • Denials, payment discrepancies, appeal success
• Medical policy analysis (across major payors for similar test types/diagnosis codes)
• Coverage determination guidance
• Data-based pricing strategy guidance
• Coding guidance
• Payor relationships

Having the right data can help providers align billing teams with individual payors, build productive relationships with payors, and justify coverage expansion. RCM partners can also help providers with guidance on how to get local coverage determination (LCD) reconsideration, justify the removal of prior authorization requirements, and handle situations where MCOs are not paying even when patients meet LCD.

The right RCM partner can also share data to help providers determine when/if appeals escalation is worth the effort, how to conduct Level 3 appeals when warranted, and how to request longer timely filing limits when they are justified (e.g., whole exome sequencing).

Collaboration Across Teams

Achieving market access goals requires collaboration across departments. Breaking down barriers to payor coverage and reimbursement is no small task, but it is achievable with the right strategy and support. By partnering with an experienced RCM provider, healthcare organizations can:

• Streamline billing processes
• Enhance compliance with payor requirements and
• Drive sustained growth

Regular communication, shared goals, and collaboration help ensure coverage is achieved and reimbursement is maximized.

If you missed part 1 or part 2 of this series, read them here:

Part 1: Building a Strong Foundation: How Market Access Teams and RCM Partners Drive Coverage SuccessRead MorePart 2: Data-Driven Strategies for Market Access: Leveraging RCM Insights to Overcome ChallengesRead More

CPT is a registered trademark of the American Medical Association