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.

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