The Symbiotic Relationship Between Market Access and Revenue Cycle Management

Molecular diagnostics laboratories frequently deal with four frustrating challenges: achieving payor coverage, securing reimbursement, understanding coding requirements, and staying compliant with evolving payor policies. These hurdles highlight the critical need for collaboration between market access and revenue cycle management (RCM) teams within the healthcare sector. Both teams play pivotal roles in ensuring healthcare providers’ financial stability and sustainability.

Billing teams are entrusted with the responsibility of maximizing reimbursement for services rendered, while market access teams are dedicated to ensuring the accessibility and coverage of these services by payors. Market access and billing constitute interrelated functions within healthcare organizations, and their collaborative efforts are essential for achieving successful financial viability and patient access to healthcare services.

Here’s how each team supports the other:

The collaboration between market access and billing teams extends beyond mere coordination—it is indispensable for the success of a healthcare organization. Together, they ensure that patients receive essential care, healthcare providers receive fair compensation, and the organization remains compliant with industry standards and regulations.

The foundation of this collaboration begins with an analysis of the data that can be extracted from the revenue cycle management (RCM) process. Access to this billing data empowers market access teams to make informed decisions, optimize reimbursement processes, negotiate effectively with payors, and guarantee that healthcare services are appropriately covered and billed.

Revenue cycle management (RCM) teams can substantially aid market access efforts by leveraging their expertise and data-driven insights. Here’s how RCM teams can support market access:

• Data Analysis and Insights: Handle a wealth of billing and claims data, encompassing not only the billing for your tests or services but also spanning their entire client portfolio. They can analyze this data to provide insights into the financial performance of various services, payors, and patient demographics. These insights are invaluable for helping market access teams identify opportunities to expand payor coverage and optimize reimbursement.
• Coverage Determination Support: Can assist market access by sharing data on services that have consistently received reimbursement and those that have faced challenges. Some payors may have medical policies that include a larger range of ICD-10-CM codes that support medical necessity. This data can support greater coverage with other payors or inform decisions regarding which services to include in coverage determinations.
• Claims Denial Analysis: Can aid market access by analyzing claims denials. Identifying common denial reasons and trends enables collaborative efforts to address root causes and prevent future denials, contributing to smoother reimbursement processes. Furthermore, this data serves as the foundation for establishing a successful appeals strategy.
• Contract Negotiations: Teams often possess insights into contractual agreements with payors. They can support market access in negotiating favorable terms by providing data on current reimbursement rates, payment timelines, and performance metrics. RCM teams can also monitor payor adherence to contracted terms and identify payors who are not paying at the negotiated rate.
• Billing Compliance: Billing compliance is crucial for both RCM and market access teams. RCM teams can share their knowledge of billing compliance standards and regulations, helping market access teams develop strategies to maintain compliance and avoid legal issues.
• Revenue Forecasting: Provide revenue forecasting based on historical data and trends. This information assists market access teams in assessing the financial implications of adding new services or negotiating with payors.
• Patient Demographic Analysis: Share patient demographic data, enabling market access teams to target specific patient populations and tailor coverage determinations accordingly.
• Coding Expertise: Are well-versed in medical coding. Collaboration with market access teams ensures that coverage determinations align with appropriate coding practices, reducing the risk of claim rejections.
• Monitoring Industry Changes: Always informed about changes in healthcare billing regulations, industry standards, and medical policy changes including MUE or NCCI edits. They can keep market access teams updated on relevant changes and collaborate on adapting strategies accordingly.

In summary, RCM teams can be invaluable partners for market access teams by providing data-driven insights, expertise in billing and claims management, compliance guidance, and support in negotiating favorable contracts with payors. Collaboration between these teams can lead to more effective revenue generation and management for healthcare organizations.

Additional Resources

The molecular diagnostics industry is rapidly growing. Read our white paper, The Executive’s Guide to Molecular Diagnostic Market-Share Expansion, to learn practical approaches, process enhancements, and payor strategies essential to growing novel diagnostic market share.