Healthcare is at a pivotal moment, leveraging technological innovation to transform the industry. Revenue cycle management (RCM) is embracing these advances to address critical challenges, such as managing increasing volumes of unstructured billing data and ensuring robust data security in an era of rising cyber threats. Simultaneously, the industry faces a growing skills gap, making it more crucial than ever for clinical laboratories to adopt technology that can effectively oversee the complexities of clinical data and billing. As these needs expand, clinical labs are moving towards more sophisticated technological solutions to streamline their business operations and improve accuracy in both data management and revenue cycle processes.
We reached out to RCM companies to share their perspectives on the future of revenue cycle management for clinical and anatomical pathology laboratories. Our panel of leading RCM firms unanimously agrees that the top priority is securing and protecting billing and healthcare data from fraud and cyber threats. They also share concerns about the growing complexities of the reimbursement process, billing for new types of tests and regulatory compliance. This article presents direct insights from Coronis Health, SYNERGEN Health, TELCOR and XiFin: how they see the market, the challenges faced by their customers and how they are leveraging technology and innovation to address them.
Dark Daily: What are a few of the key market trends you see that will impact your RCM clinical laboratory customers over the next few years?
Coronis Health: The lab revenue cycle management (RCM) market is grappling with significant challenges, largely driven by declining reimbursements resulting from ongoing PAMA cuts. These cuts create a downward spiral where Medicare rates are based on the lowest private payer rates, forcing labs to operate with fewer resources while facing higher demand. This is compounded by a worsening physician shortage, making it harder to maintain staffing levels and service quality.
Additionally, patients are increasingly responsible for medical costs, and changes like medical bills no longer affecting credit scores have made collections more difficult. The rise in fraud and cybersecurity concerns has also led to hesitancy around new payment methods, further complicating revenue recovery. These issues highlight the need for innovative solutions to ensure lab operations can thrive in this challenging environment.
SYNERGEN Health: The growth of precision medicine is fueling the increased regulation and reporting requirements as one of the largest impacts on laboratory billing services. As precision medicine continues to grow, we anticipate more regulations and reporting requirements as well as more stringent controls for payers to ensure compliance and transparency. The rapid advancement and adoption of genetic testing are likely to outpace payer systems, exacerbating reimbursement issues and requiring new approaches to streamline claims processing and payment accuracy.
TELCOR: Insurance companies are pushing more responsibility to patients for the payment and dispute of medical expenses. Deductible amounts continue to rise leaving more claims to be paid by patients. Additionally, more payers require patient consent to appeal claim denials, especially for out-of-network laboratories. These trends are especially hard on laboratories as they rarely have direct contact with the patient. Patients are often unaware of the lab conducting the test; therefore, requests for information or payment are met with skepticism or outright ignored.
XiFin: The rising costs of cybersecurity and regulatory compliance are major challenges impacting laboratory RCM. The cost of doing business is increasing as laboratories and RCM providers invest in robust cybersecurity measures while navigating complex regulatory landscapes. FDA oversight, federal and state-specific regulations, and plan-level nuances in payer policies demand significant attention and resources. Additionally, rising patient bad debt rates are further eroding margins across the healthcare sector.
A competitive labor market and the growing demand for specialized RCM skills create challenges in recruiting, retaining, and upskilling talent. Expertise in navigating payer-specific requirements and utilizing advanced technologies is becoming more critical than ever. Meanwhile, payor rules are becoming more fragmented and granular, requiring laboratories to adapt to increasingly complex multi-layered regulations. This shift places a premium on data-driven decision-making and operational flexibility.
As laboratories rely more on seamless interfacing with electronic medical records (EMRs), the need for platforms with robust interoperability continues to grow. Challenges related to data integration can impact claim accuracy, timeliness, and overall operational efficiency, further complicating the revenue cycle management process.
Dark Daily: What impact do you foresee these market trends will have for your RCM customers?
Coronis Health: Declining reimbursements, patient payment challenges, and rising cybersecurity threats, will all demand that RCM customers embrace greater efficiency, innovation, and adaptability. To address these, Coronis Health is leveraging technology to enhance patient access and simplify payment processes. Expanding text-based payment options, which align with the growing preference for mobile solutions, not only boosts patient satisfaction but also improves collections by meeting patients where they are most engaged.
We also utilize advanced AI tools like Ai4AR, which employs machine learning to combat payer denials by analyzing patterns and adapting over time. This technology streamlines operations and enhances decision-making, enabling quicker resolutions and more effective appeals. In addition to operational advancements, Coronis Health prioritizes data security with a comprehensive risk management strategy to protect against rising fraud and cyber threats. By combining patient-centric innovations, adaptive AI, and strong security measures, we are helping our clients navigate challenges and maintain financial health in an evolving landscape.
SYNERGEN Health: Recent developments in the laboratory industry are having a profound impact on revenue cycle management.
One major challenge is the increased complexity in coding and documentation, driven by the emergence of new tests. As laboratories are often forced to use unspecified codes, this creates a need for more detailed documentation, which can delay reimbursements and increase the administrative burden on staff.
At the same time, the rising demand for molecular and genetic testing has introduced growing reimbursement challenges and an increase in prior authorization requirements. To manage these hurdles and address staffing/resource limitations, automation tools are becoming increasingly essential. These tools help streamline processes, reduce manual workloads, and improve overall efficiency, ensuring laboratories can better navigate the evolving landscape of reimbursement and operational demands.
TELCOR: The structure and interconnectedness of payers continues to get more complex. Medicare not only has different MACs (Medicare Administrative Contractors), but it also has multiple Advantage plans that can cross MACs. Medicaid has a main plan in each state as well as multiple managed care plans in each state. Each of these commercial plans has their own rules and processes even if they are supposed to be following Medicare/Medicaid. Additionally, not all Medicare MACs follow the same rules, having their own LCDs (Local Coverage Determinations) that make coverage different for each area of the country.
Commercial payers remain complex as they may have different coverage and processes based on home plans, appeals processing, testing type, and individual patient plans. Appeals may go directly to the payer except for certain genetic testing that goes to a third-party administrator. Coverage for molecular testing may not be covered except for a specific employer that has negotiated different coverage. A commercial payer may choose to adopt Medicare rules for the majority of their coverage, except for a carve out of certain tests. While these issues are not all new, they continue to grow and impact payers and claims.
XiFin: At XiFin we have identified several trends that present both challenges and opportunities for clinical laboratory RCM customers. As cybersecurity and compliance costs rise, laboratories must find efficiencies in other areas to maintain financial health and operational agility. Automating RCM processes has become essential, and tools designed to increase patient engagement and improve the likelihood of payment will be highly valued.
Additionally, outsourcing RCM functions to specialized providers offers laboratories access to economies of scale, advanced technology, and a skilled talent pool capable of navigating complex regulatory and payer landscapes. At the same time, customers are increasingly relying on RCM data, expanding its use beyond financial operations to inform strategic decision-making across their organizations.
Dark Daily: What are some of the strategic innovations you are focused on offering your customers in the next few years to help customers meet these changes?
Coronis Health: We are deploying innovative technologies and services that enhance efficiency, patient engagement, and data security. A key initiative is the rollout of text-based patient statements, providing a convenient and accessible way for patients to manage and pay bills. This aligns with consumer expectations and improves payment rates by meeting patients where they are most engaged.
We are also leveraging AI tools to streamline denial management, consolidate patterns, and enable quicker resolutions. These tools allow teams to focus on high-value tasks while reducing revenue leakage and improving compliance.
To combat rising cyber threats, Coronis Health has implemented a robust security and risk management program to protect sensitive data and systems. Additionally, advanced data analytics capabilities are being developed to provide customers with actionable insights, empowering them to optimize revenue cycle performance and adapt to an ever-changing healthcare landscape.
"The next several years will offer an abundance of opportunities to confront and navigate the endless challenges presented by declining payor reimbursement, legislation/regulatory changes and the impending personnel replacement needs. While strong technical solutions such as AI and Business Intelligence tools will be critical to this journey, we must also consider improved RCM process efficiency, transparency and, quite frankly, good old fashioned “roll-up-your sleeves” hard work as the true steppingstones for success. " — Chad Scribner, Senior Vice President, Lab & Path, Coronis Health
SYNERGEN Health: At SYNERGEN Health, we are continuously enhancing and optimizing our technology solutions to address the growing reimbursement challenges. Our tools are designed to capture patient demographics, verify benefits, and streamline the charge capture process, ensuring a more efficient order entry process and producing cleaner claims. Additionally, leveraging automation to address back-end denial trends minimizes the number of manual touches needed to get a claim paid/resolved, while performing tasks in bulk improves overall efficiency and accuracy.
"Labs across the U.S. are suffering from a lack of RCM integration and automation capabilities coupled with an increase in denials due to missing information and prior authorizations. Our denial management solution is built on continuously evolving AI technology with a strong focus on enhancing machine learning modules, predictive analytics, rule engines and Natural Language Processing (NLP) capabilities. We consistently improve our machine learning algorithms to adapt to new patterns and trends in denial data, enabling more accurate identification of denial causes and automated resolution recommendations. By refining predictive analytics, our system proactively forecasts potential denials based on historical data, payer behavior, and claim characteristics, empowering your team to prevent issues before they occur. Additionally, our NLP enhancements enable deeper understanding and categorization of denial messages, ensuring precise interpretation of payer communications and efficient processing of unstructured data.
These continuous advancements ensure that our solution remains at the forefront of denial management, delivering faster resolutions, improved cash flow, and reduced administrative burden." —Teri Gatchel-Schmidt, Vice President, Business Development and Consulting, SYNERGEN Health
TELCOR listens to our customers to ensure their specific needs to tackle these challenges are met. We make sure they can see all their AR data in real-time from one application, provide smart workqueues to streamline processes to reduce manual intervention, and deliver the business intelligence needed to make smart business decisions. One of the many ways we do this is through powerful workqueues for prior authorization and claim appeals allowing laboratories to incorporate their specific requirements and documents based on each payer and type of test performed. Using AI, prior authorization and appeal packages are compiled automatically and faxed or uploaded to payer sites with ease. Because this is built into the system, it removes the guesswork and manual intervention required to align appeals and prior authorization activities with a customer’s market access strategy. Although the complexity of payer regulations is ever increasing, the TELCOR RCM technology continuously accommodates those updates to meet the needs of any lab. The flexibility and control within the application to adapt rules as needed, allows labs to adjust quickly to new requirements, prevent future denials, and overall improve collections.
"These trends lead to increased labor with decreased reimbursement, and the burden falls squarely on laboratories. Increased dependence on patient payments means labs have to be more proactive and aggressive in order to be paid for their services. But labs have to balance this against both patient and provider satisfaction so ordering providers do not take their business elsewhere." — Sarah Stewart, Vice President, TELCOR
XiFin: To help laboratories navigate the evolving landscape, XiFin is focusing on delivering practical solutions and forward-looking technologies. Many customers are actively collaborating with us on our AI initiatives and are finding XiFin’s targeted applications of Natural Language Processing (NLP) and Machine Learning (ML) to be highly effective. These technologies are being applied to payor responses to optimize claims processing by interpreting unstructured text, prioritizing claim errors based on reimbursement likelihood or value, automatically routing claims to the best-suited team members, minimizing manual intervention with automatic RCM updates, and reducing patient call volume for insurance or demographic information.
Additionally, laboratories are increasingly focused on simplifying and consolidating their system architectures. This aligns with our approach of providing an RCM platform that offers broader functionality and seamless integration, ultimately reducing inefficiencies and improving data flow with EMRs and other systems. Moreover, our emphasis on expanding API-driven connectivity ensures real-time data exchange, allowing laboratories to access up-to-date information for better decision-making and operational efficiency.
"The coming years will challenge laboratories to adapt to workforce shortages and mounting regulatory demands and will require them to adopt workflow automation technologies with embedded AI. Through strategic investment in AI, interoperability, and next-generation business intelligence, we are committed to empowering our RCM customers with the tools they need to not only navigate these challenges but excel in today’s increasingly complex healthcare landscape." — Kyle Fetter, COO, XiFin