New Reimbursement Models May Expand the Role of Eligibility Checking

The winds of change are turning into gale-force winds when it comes to the new reimbursement models for physician practices. High-deductible plans and industry-wide reimbursement changes are substantially increasing the financial responsibility of patients, forcing practices to focus a larger percentage of their collection efforts on their patients to remain profitable. Consider the following:

  • According to the 2013 PwC Touchstone Survey of major U.S. companies, 44 percent of employers are considering offering high-deductible health plans as the ONLY benefit option to their employees in 2014. That’s a whopping 31 percent increase from just two years ago.
  • Now, $12,700 is the new maximum out-of-pocket cost limit for a family, and $6,350 is the limit for individuals.
  • As the trend for care continues to move out of hospitals and to physician practices and walk-in-clinics, physicians and office managers will need new methods to collect balances owed from deductibles, coinsurance and co-payments.

Looking into the future, these changes may greatly expand the role of patient eligibility checking, leading to systems that automate many processes, including:

  • Front-end adjudication systems may determine procedure level and medical necessity requirements prior to care delivery, which would improve workflow.
  • Patient financial responsibilities may be better detailed and automated during the eligibility verification process.
  • In addition to determining patient financial responsibility, practices may also have the ability to leverage reporting services that predict which patients are most likely to pay their balances.

These changes may also evolve how practices operate. With patients shouldering greater percentages of financial responsibility, many patients are unable to afford the care offered by practices. Some forward-thinking practices may evolve to offer micro-financing services to help patients pay for the care they receive.

Tell Us Your Thoughts

How do you think patient eligibility verification will evolve in the future? Leave your thoughts in the comment section.


Eligibility Checking – The Necessity of Live Representative Calls to Payers

Today’s physician practices have more opportunities than ever to automate tasks using electronic health record (EHR) and practice management (PM) solutions. While increased automation can offer numerous benefits, it’s not appropriate for every situation.

Specifically, there are certain patient eligibility checking scenarios where automation cannot provide the answers that are needed. Despite advancements in automation, there is still a need for live representative calls to payer organizations.

For example, many practices use electronic data interchange (EDI) and clearinghouses with their EHR and PM solutions to determine if a patient is eligible for services on a specific day. However, these solutions are typically unable to provide practices with information about:

  • Procedure-level benefit analysis
  • Prior authorizations
  • Covered and non-covered conditions for certain procedures
  • Detailed patient benefits, such as maximum caps on certain treatments and coordination of benefit information

To gather this type of information, a representative must call the payer directly. Information gathered first-hand by a live representative is vital for practices to reduce claims denials, and ensure that reimbursement is received for all the care delivered. The financial viability of the practice is dependent upon gathering this information for proper claim creation, adjudication, and to receive timely payment.

Many practices, however, do not have the resources to complete these calls to payers. In these situations, it may be appropriate for practices to outsource their eligibility checking to an experienced firm.

Tell Us About Your Experiences

What are some of the EHR/PM limitations that your practice has experienced when it comes to eligibility checking? How often does your practice make calls to payer organizations for eligibility checking? Let me know by replying in the comments section.



Top 5 Overlooked Methods Proven to Increase the Efficiency, Accuracy of Eligibility Verifications

Changing policies.New forms.Added steps to the process. Pick any of these, yet alone the longer laundry list of the issues associated with eligibility reporting, and it’s understandable why many practices struggle with staying current and optimizing the tools available to them. I correlate it to taxes – tax accountants are paid to stay current with everything and thus maximize the return to each customer.

The same can be said for physician eligibility verification. There are specialists you can outsource to, ultimately optimizing the process for the practice. For those who maintain the eligibility in-house, don’t overlook proven methods. Abide by these tips to help assure you get it right every time and lower the risk of insurance claim issues and maximizeyour revenue.

Top 5 Overlooked Methods Proven to Increase the Efficiency, Accuracy of Eligibility Verifications

  • Verifying existing and new patient eligibility each and every visit: New and existing patients should have their eligibility verified Every. Single.Visit. Quite often, practices do not re-verify existing patient information because it’s assumed their qualifying information will remain the same. Not the case. Change of employment, change of insurance coverage or company, services and maximum benefits met can alter eligibility.
  • Assuring accurate and complete patient information: Mistakes can be made in data entry when someone is trying to be speedy for the sake of efficiency. Even the slightest inaccuracy in patient information submitted for eligibility verification can cause a domino effect of issues. Triple checking the accuracy of your eligibility entries will seem like it wastes time, but it will save time in the long run saving practice managers from unnecessary insurance company calls and follow-up. Be sure that you have the patient’s name spelling, birthdate, policy number and relationship to the insured correct (just to name a few).
  • Choosing wisely when depending on clearinghouses: While clearinghouses can offer quick access to eligibility information, they most times do not offer all necessary information to accurately verify a patient’s eligibility. More often than not, a call made to a representative at an insurance company is necessary to gather all needed eligibility information.
  • Knowing exactly what a patient owes before they even arrive at the appointment: You should know and be ready to advise a patient on the exact amount they owe for a visit before they even arrive at the office. This will save money and time for a practice, freeing staff from lengthy billing processes, accounts receivable follow-up and even enlisting the help of credit bureaus to collect on balances owed.
  • Having a verifications template specific to the office’s/physician’s specialty. Defined and specific questions for coverage pertaining to your specialty of practice will be a major help. Not all specialties are the same, nor are they treated the same by insurance company requirements and coverage for claims and billing.


As we said, it’s practically impossible for all practice operations to run smoothly. There are inevitable pitfalls and areas prone to issues. It is important to establish a defined workflow plan that includes mix of technology and outsourcing if needed to achieve consistency and accountability.

Eligibility Checking Part 1: Determining Patient Financial Responsibility

The healthcare landscape has changed, and one of the biggest changes is the growing financial responsibility of patients with high deductibles that require them to pay physician practices for services. This is an area where practices are struggling to collect the revenue they are entitled.

In fact, practices are generating up to 30 to 40 percent of their revenue from patients who have high-deductible insurance coverage. Failing to check patient eligibility and deductibles can increase denials, negatively impact cash flow and profitability.

One solution is to improve eligibility checking using the following best practices:

-Check patient eligibility 48 to 72 hours in advance of scheduled visit using one of these three methods:

  1. Business-to-business (B2B) verification, which enables practices to electronically check patient eligibility using electronic data interchange (EDI) via their electronic health record (EHR) and practice management solutions.
  2. Look up patient eligibility on payer websites.
  3. Call payers to determine eligibility for more complex scenarios, such as coverage of particular procedures and services, determining calendar year maximum coverage, or if services are covered if they take place in an office or diagnostic centre. Clearinghouses do not provide these details, so calling the payer is necessary for these scenarios.

-Determine patient financial responsibilities – high deductibles, out-of-pocket limits, then counsel patients about their financial responsibilities before service delivery, educating them on how much they’ll need to pay and when.

-Determine co-pays and collect before service delivery.

Yet, even when doing this, there are still potential pitfalls, such as changes in eligibility due to employee termination of patient or primary insured, unpaid premiums, and nuances in dependent coverage.

If all of this sounds like a lot of work, it’s because it is. This isn’t to say that practice managers/administrators are unable to do their jobs. It’s just that sometimes they need some help and better tools. However, not performing these tasks can increase denials, as well as impact cash flow and profitability.

In our next post we will examine ways to overcome these challenges.

Outsourced Claim Creation for Physician Practices

A great deal of expertise goes into running a successful physician practice – from the skilled clinicians who deliver patient care, to the front- and back-office staff who manages the business aspects of the practice. Yet, after focusing on the care delivery aspects of the business, many practices often don’t have enough time to properly focus on their billing tasks. This prevents practices from earning the maximum reimbursement for the services they performed.

In these situations, outsourcing billing tasks – such as claim creation –  is worth consideration. Claim creation services are able to devote their entire attention to the practice’s revenue cycle management (RCM) process, and are focused on keeping up to date with ongoing regulatory changes to reduce claim denials and maximize reimbursement.

Once a practice outsources its claim creation, the process is initiated with one of two options to begin claim creation:

  1. The practice scans superbills and patient demographics to electronically send to the claim creation team. This may also include scanning the billing data and consult information from hospitalists to send to the claim creation team.
  2. The practice ships superbills, patient demographics, and other relevant billing information to the claim creation team.

Once documents are received by the claim creation service, there are typically two ways to generate a claim:

  1. Manual Claim Entry: Before any claim is generated, patient insurance verification is done. Claims are then created from a route slip, superbill and other billing information. Claims are then scrubbed for errors that may cause denials. Once claims are created, they can be either sent back to the practice for submission, or the claim creation service can electronically submit the claims.
  2. Electronically Generated Claims: This process is sometimes known as Autogeneration. These claims are created using the evaluation and management (E&M) coding engine within the practice’s EHR interface. Additionally, these claims can be created by using the electronic superbill within the practice’s EHR system, or can use the charge capture system within the practice management system. Auditing of the newly created claims can still be done before submission by either the practice or the claim creation service.

Outsourcing the claim creation process benefits practices on multiple levels. It enables them to remain focused on care delivery, while also ensuring that they receive maximum reimbursement for the services they deliver.