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.
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.
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.
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:
- 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.
- Look up patient eligibility on payer websites.
- 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.
Did you know that between 2009 and 2012, insurance denials for claims for reasons like inclusive procedures, not meeting medical necessity, required medical documentation, among others, has increased by almost 37 percent? Additionally, did you know on average, 32 to 35 percent of claims can go unaddressed for lengthy periods of time costing practices real money? Should we even mention patient responsibility for one claim visit has increased from approximately $12 to $30 on average?
It’s as if getting money in the door for your practice has become increasingly impossible. If it’s not one thing keeping you from healthy revenue, it’s another.
While we at ClinicSpectrum offer a number of easy and comprehensive ways for you to streamline the accounts receivable process (there is help!), we also want to take a moment to inform you of some of the common ways practices lose money, and to laugh at the hilarity and sometimes sad instances when claims get denied or patients won’t pay their remaining responsibility.
And so we present to you the top 3 silliest and needless ways to lose money in the A/R process:
- Following up with patients on their owed amount following insurance collection, and even alerting credit agencies to past-due balances is about as fun as a cross fit class. It’s just plain exhausting. With patient deductibles increasingly susceptible to larger deductible amounts with certain aspects of the Affordable Care Act (ACA), it’s no surprise that many patients get sticker shock when they receive a bill. Pair this with a lack of patient education on their responsibility before services are rendered and you’re likely to end up with a lot of “I’m not paying this.” Some people even get so emphatic that they write entire blog entries on how they simply won’t comply with Obamacare. Yikes.
Don’t lose money in the patient responsibility collection piece of accounts receivable. Educate your patients about their responsibilities before they receive a bill they might not be able to afford in full at the time. ClinicSpectrum’s Eligibility Verification can help in this area.
- We have heard terrible stories from our customers prior to our engagement, of the slightest minutia of information being listed incorrectly on a claim. These small errors, often credited to a busy office and innocent human error, can cost your practice time and money. We’ve even heard claims going unsettled for nearly one year because of a spelling error, misdiagnosis or number listed incorrectly.
To the rescue! ClinicSpectrum also has knowledgeable staff, products and solutions to make sure headaches like this don’t happen.
- You call, call, and call – and call one more time – but the insurance company is just plain UNAVAILABLE to help you on a claim. We can bet you have one thousand better things to do during your busy day than to remain ear attached to the phone hitting redial or trying to navigate complicated automated phone system menus.
ClinicSpectrum can easily save you from all of this hassle. We have a proven insurance claims follow-up process divided into three methods:
- Online Claims Follow-Up – Using various Insurance company websites and internet payer portals, we check on the status of outstanding claims.
- Automated Claims Follow-Up (IVR) – By calling Insurance companies directly, an Interactive Voice response system will give the status of unpaid claims.
- Insurance Company Representative – If necessary, calling a “live” Insurance company representative will give us a more detailed reason for claim denials when such information is not available from either websites or Automated phone systems.
Is that a collective sigh of relief we hear?
Don’t lose money when it comes to collecting money owed to your practice. Contact us for an assessment. We want to help you get money in the door.
This post was originally appeared on EMR AND HIPAA.
Eligibility verification has always been a challenging part of running a healthcare business. However, that challenge has become even more difficult as the Affordable Care Act has caused a wave of newly insured patients along with patients who are switching insurance carriers flooding into physician offices. Verifying and learning the details of the patients’ new insurance policies has created a lot of new work for a clinic’s staff.
In the perfect world, there would be an automatic verification system that would easily look up a patient’s insurance policy and the details of their plan. While some companies are trying to make automatic insurance verification a reality, it’s currently very weak and still requires a lot of human intervention and interpretation. Maybe one day the payers will fix that, but until then it’s important that a practice creates a smooth process for verifying a patient’s insurance. In many cases this includes hours browsing insurance company websites and internet payer portals or waiting on hold for hours a day on automated voice systems or insurance company call trees. Is that the best use of your staff’s time?
I don’t think I need to describe in detail why having the insurance eligibility and plan details as early as possible is important. If you don’t have this information, your ability to get paid by the patient for the services rendered goes down and your claims denials go up. Plus, many of these new insurance policies are high deductible plans where you’ll need to collect a lot more money than usual from the patient. One way to solve this problem is to know how much the patient owes before or at least while they are in the office. The best opportunity to collect from a patient is when they are standing in front of you.
While internal staff can do a great job verifying insurance eligibility and obtaining benefits summaries, this can be a challenging job while handling all of the other front desk or billing duties as well. One solution to this problem is to outsource the eligibility verification task. A list of scheduled appointments is supplied to the outside company and after verifying insurance coverage for the patients they put the coverage details directly into your appointment scheduler. Obviously the key business question here is to compare the cost, timing, and quality of an outside service against the cost, timing and quality of your current staff doing it.
One related challenge that many practices are facing with all of these new and changing insurance policies is the time staff spend educating the patients. Most patients did not spend time really understanding the insurance policy they were buying. They looked at the price and largely bought without reading the fine print. This often means your staff are tasked with sharing the details of the policy and dealing with any fallout. In some ways, this isn’t a new task. However, the volume has increased.
Another solution offices should consider is doing the eligibility verification well before their appointment. Then, using a secure messaging solution the practice can share a patients’ eligibility and plan details including any co-pays and deductibles with the patient before they even arrive at the office. This early communication gives the patient time to call their insurance provider instead of your practice for all the details. Plus, it makes the patient payment expectation clear before the patient even enters your office.
How much time is your office spending verifying insurance? What solutions are you using to improve your eligibility checking and communication workflow?
The Cost Effective Healthcare Workflow Series of blog posts is sponsored by ClinicSpectrum, a leading provider of workflow automation solutions for healthcare. Their Eligibility verification service is a great way to leverage technology and people to solve the eligibility verification problem. ClinicSpectrum also offers a secure messaging product called MessageSpectrum.
For many families, planning to spend $12,700 could mean getting a new car or college tuition. But in 2014, American families have yet another reason to save because they may need to make a big purchase on healthcare. 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. Twelve thousand, seven hundred dollars is now the new maximum out-of-pocket cost limit for a family, and $6,350 is the limit for individuals. And of course, factor in inflation and many private plans are already laying the groundwork for members that costs will only increase in 2015.
As the trend for care continues to move out of hospitals and to physician practices and walk-in-clinics, physicians and office managers running these facilities will need to be prepared to collect all of these funds which will come in the form of deductibles, coinsurance and copayments.
Fear not — we’ve got you covered on this. With our new STAT Eligibility verification, we will take care of everything from eligibility verification to checking on necessary pre-certifications, how much of the deductible the patient has met to date and much more. In stark contrast to the high deductibles, your cost is low — a simple flat fee and everything processed and sent directly through a secure portal within one hour turnaround time. Say goodbye to paper trails and time-consuming process for your staff.
I’ve seen a quote that says, “Change before you have to.” In healthcare, you can debate if it’s “before” you have to, or at the critical point of “have to.” But when change is this easy, why wait another day? Seize the moment and maximize deductible collection.
PricewaterhouseCoopers reported in 2013 that 17 percent of employers were offering high-deductible plans as their only option. That’s a 31 percent increase over 2012. Forty four percent of employers said that high-deductible plans would be their only option in 2014, according to PwC. This rise started in traditional health plans, and with the rollout of the Affordable Care Act, we are seeing more high-deductible plans being offered, and they present quite a challenge to physician practices. In this new environment, practices need to think more like a business so they cannot just survive, but be profitable.
Attributed to the famous Spanish painter Pablo Picasso is the phrase, “action is the foundational key to all success.” For physician practices, that action in regard to the trend of increased deductibles is assuring that it is a priority to operate as an efficient business to collect on these deductibles.
And that proper collection needs to start with eligibility and out-of-network benefits verification that is conducted prior to the patient even arriving for their visit.
Too often we hear stories from practices who cannot recoup the out-of-pocket deductibles after the patient leaves the office, or who continue to get claims rejected by the insurance companies because the services rendered are not covered under that plan. Sound familiar? So, instead of nodding in regretful agreement, implement a hybrid workflow model that starts with back office expertise in providing eligibility verification.
It is more important than ever to run proper eligibility checks to confirm what plan and coverages the patient has (under ObamaCare alone there are four new types of plans, and each different for individual or family) what the deductible is, and if the deductible has been met yet or not.
Eligibility checking is also the single most effective way of preventing insurance claim denials. We begin with retrieving a list of scheduled appointments and verifying insurance coverage for the patients. Once the verification is done the coverage details are put directly into the appointment scheduler for the office staff’s notification.
At ClinicSpectrum, our services cover the three methods for checking eligibility including online websites and portals; automated voice system (IVR), and directly calling insurance companies to gather more information. And we’ve proven that our methods work.
So focus on care, and let us focus on the eligibility check. Tackling this challenge at the start of a patient encounter will alleviate bigger operational and financial stresses down the road.