The Value of Payor-Specific Appeals Automation

Clarisa Blattner
Senior Director MDx Support Services, XiFin

Scott Burk
Client Success Manager, XiFin

The growing number of appeals and the high costs associated with them is a challenge for many laboratories and diagnostic providers. These costs are exacerbated if the laboratory uses a traditional billing system that provides little or no automation or relies on manual processes. Needing to submit payor-specific forms and letters further increases the required effort and cost. It is possible and practical to automate much of the appeals process, including payor-specific requirements. The number of denials and need for appeals is only growing, so now is the time to think about automation.

Traditional management of denials and appeals is perhaps the most labor-intensive aspect of the revenue cycle management (RCM) process. While standardized efforts to overturn denials have proven fruitful in many scenarios, successful appeals management is not a one-size-fits-all approach. This is especially true as more payors require custom forms and letters of medical necessity and ever more supporting documentation. 

As you look to optimize your RCM processes and costs, consider a next-generation RCM solution that includes denials and appeals automation, including: 

• Configurable reason code-specific logic and workflows
• Automated data population into proprietary appeal forms and payor-specific letters
• Production and submission of proprietary payor forms and payor-specific appeals letters (based on an American National Standards Institute (ANSI) denial code)
• Attachment of any anticipated or requested supporting documentation (e.g., medical necessity, prior authorizations, patient requisitions, test results, etc.) to the claim

With XiFin RPM, much of the multi-faceted denials and appeals management process can be automated, including the attachment of additional documentation and generation of payor-specific appeal letters and forms. This appeals automation is tailored based on each claim’s ANSI denial code.

Most XiFin customers choose to appeal any payor denials based on medical necessity/experimental and investigational. These appeals may require appropriate medical records and payor-specific forms and letters. To facilitate this automation, XiFin offers a document management capability that includes features such as:

XiFin recommends diagnostics providers educate their referring physician offices on the benefits of gathering needed clinical/medical documentation up front — during patient registration. Using XiFin’s client portal, the information is readily passed into the XiFin RPM system and reduces the need to circle back to the practice weeks later, when it will be added time and inconvenience to the provider. It does require some initial engagement with the physician practices, but it is much less work than trying to get the information 60-90 days later. Some diagnostic providers are hesitant to ask this of their clients for fear of impacting potential sales – but physician and patient expectations have changed. Physicians have patient experience and engagement as a top priority. This is a diagnostic provider’s opportunity to demonstrate the potential adverse patient experience physicians and their teams may be inadvertently causing.

XiFin RPM also provides the capability to quickly generate bulk appeals with all supporting documentation submitted with the payor-specific appeal forms and letters right away. For clients who choose to outsource their billing to XiFin, our team analyzes the top ANSI denial codes and payors each month to provide automation solutions to get the lab paid more often and faster. For example, we may see a bundling denial that requires us to write consolidation logic to append a modifier to identify a distinct procedure for the payor.

Conclusion

Maximizing revenue and the effectiveness of workflow depends on the use of automation. With appeals being one of the costliest revenue cycle processes, it’s a natural place for robust automation. Automating the appeals management process and incorporating payor-specific requirements improves appeal success rates and the speed with which providers get reimbursed. With the significant increase in appeals — and the cost burden associated with them — an automated appeals process is a necessity for hospitals, laboratories, and other diagnostic providers.

Request a demo of the denials and appeals management capabilities today.

Discover more on how to reduce the burden, cost, and complexity of prior authorizations and appeals here. 

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