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.


Start a Discussion

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s