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.

 

 

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