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.

Needless Ways Your Practice Is Losing Money

bank-notes-bills-buy-2114-723x550Did 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:

  1. Online Claims Follow-Up – Using various Insurance company websites and internet payer portals, we check on the status of outstanding claims.
  2.  Automated Claims Follow-Up (IVR) – By calling Insurance companies directly, an Interactive Voice response system will give the status of unpaid claims.
  3.  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.

Don’t Lose Money as Deductibles Rise — Verify Eligibility

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.

Going up! Effectively using eligibility verification as deductibles increase

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 Overworked tired doctor at computerwho 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.

Automated Billing: Increase Time with Patients, Practice Profitability

Physician practices are very aware of the growing amount of deductible collection that will be necessary with the huge influx of eligible patients under the Affordable Care Act. But while they are very aware, this doesn’t necessarily mean they have measures set up to best prepare for this influx. If they have set preparatory measures, are those measures helping to simplify processes and work flow, or is there now just more work to be done?

Eligibility All of the physicians I work with go into practice to help and heal people. They didn’t study medicine to then explore the ins and outs of all things payer, billing, and appointment reminders. For those with smaller practices, they and maybe one other clinical staff member are multitasking; handling everything from diagnosis to accounts receivable follow-up, and even eligibility verification. Add back- and front-office operations to that and you’ve got a formula for loss in revenue and harried business operations. Some of the most prevalent and common issues I see physicians’ practices face include:

  •  Increased cost in overall operations
  • Reimbursements and revenues decreasing
  • High deductibles or increased patient deductibles
  • Delays in collection of deductibles and other balances due to billing inaccuracies
  • Employee compensation increases
  • Overall inflation of business operation costs
  • Confusion about healthcare reform specifications for small- to mid-sized practices
  • Failure or lag in communications through traditional phone calls and mailed letters

But there is a better way: Automating billing and collection systems that will maximize profitability and increase time with patients. While undoubtedly there will be skepticism from some physicians after a decade of the failed promises of enhanced productivity and improved care from many EHRs and other systems, automated billing can be done, and at a cost that won’t elicit sticker shock. You can:

  • Streamline collection methods. This can often be a bane for back-office operations to say the least. Manual collections often result in massive amounts of paper records, hard copy mailings, and staff hours following up with patients on balances owed. Your office staff should be welcoming patients and becoming more involved in their care to help keep them with the practice; not manually dialing phone number after phone number so you can get dollars in the door. Additionally, just because you have the staff to do the office work, doesn’t necessarily mean that work is done cost-effectively and successfully.
  • Increase/better target use of communication such as secure text, e-mail, and phone calls. Similar to my above point, free up your back-office operations to do the most important things for your practice. By targeting communication channels specific to your patients’ likes and needs, you streamline your practice operations. You aren’t hard-copy mailing a young patient who only responds to text messages. You aren’t e-mailing a patient who checks e-mail once every month.
  • Report non-responsive debtors to credit bureaus and/or legal departments to take the workload off of the practice staff. By automating processes, your staff isn’t bogged down by work when people don’t pay. There are solutions to freeing up their time and making sure your practice profits.

Here’s an example that might apply to your practice: Take a look at your eligibility verification. If each claim denial costs your practice $25 to $30, and you know your denial rate is above the industry average of 3 percent, the monthly cost for eligibility verification in advance of patient visits shows an outsourcing company with this specialty effectively pays for itself. As a patient, and with friends and family who are patients, I want to know that when I see the doctor that he is able to be clear minded and exclusively focused on my care or the care of my family member. With automated billing solutions in place, physicians can focus on the practice of medicine, freeing their time to focus on patient care, and work with their office staff to maximize profitability. Vishal Gandhi is chief executive officer of ClinicSpectrum, leaders in hybrid work flow solutions consisting of both an innovative software suite and back-office operations. E-mail him here. See more at: http://www.physicianspractice.com/blog/automated-billing-increase-time-patients-practice-profitability#sthash.rsbGuhJD.dpuf

ClinicSpectrum’s In- House STAT Eligibility Verifications Solution

Eligibility Verification by Clinicspectrum

Although perpetual breakthroughs and continuous innovations in the field of medicine and technology offer people improved quality of life, the fact remains that the cost of medical care is on the rise.   For many, health coverage is a huge concern, as some have not renewed their plans or don’t have the adequate insurance for their medical needs.  The high monthly premiums have put off many people, but choosing not to enroll is an even more expensive decision.

Under the recovery act, the main contentions are:

  • Preventative care must be covered by insurance
  • A pre-existing condition does not mean the insurance will be denied, neither will it involve greater deductible

On the flipside:

  • Insurers can no longer place lifetime caps on the deductible to be paid
  • Americans without an insurance plan will have to get one, or pay a designated penalty

With some benefits as “no denials” or “extra deductible for conditions”, people are quite keen and eager to promote the act, despite its breakdowns.   Moreover, even with a high deductible, you still pay much less than you would while paying out of pocket medical expenses incurred by care.  ClinicSpectrum’s eligibility verifications solution is a prime choice for these circumstances. ClinicSpectrum’s STAT Eligibility Platform, a seamless eligibility verifications solution is vital to clinicians. Under the new health care act, the influx of eligibility for patients will increase manifold and tracking high deductibles in an efficient manner may prove difficult and downright taxing. ClinicSpectrum proposes to use the software based on eligibility criterions and patient records, through complete automation of the processes involved.  STAT Eligibility secure portal will replace traditional emails, phone, and other manual services, and will provide concrete, relevant benefits data within 45 minutes of turnaround time.  This is also going to mean a significant reduction in the manpower required for operations, through our electronic verifications system.  It additionally also uses a real time connection with insurance companies, websites, and clearing houses, all while the communications are delivered by the ClinicSpectrum back office team.

Operational Cost Reduction in a Changing Healthcare Environment

With cutting edge technology and daily medical breakthroughs our healthcare system appears to fit the mold of streamlined perfection, however the rising challenges of daily medical group operations are quietly overlooked without an obvious solution.

Doctors are challenged to divert their focus from treating patients, to tedious claim chases and endless denial follow ups, causing additional frustrations to the already perplexed lowered insurance reimbursements. Office managers are equally defied; faced with high turnovers, limited solutions and high operational costs, the days at the office just got longer. And it’s no wonder, as the cost of maintaining a profitable business the old fashioned way is not a sustainable option.

So what is the solution? Hybrid workflow! Imagine this: You walk into your office, log in to your computer and the first email you see depicts a picture perfect world, full of clarity and insight. Easy to understand spreadsheets with complete breakdowns of outstanding accounts receivables and valid reason explanations for easy claim correction and resubmission. Or better yet, a full report of your patients’ appointments confirmed in advance with detailed eligibility and benefits verification with authorization codes available prior to treatment. How about pages of scanned documents which are seamlessly indexed to their designated folder? It can happen! I know what you are thinking, this is too good to be true, a sci-fi flick with virtual reality inserts, no such solution exists in real life. Wrong!

Eligibility Verification

Unique back office solutions can significantly enrich your current workflow in the areas of Claims Entry, Payment Posting, Accounts Receivable Follow Up, Denials Management and Credentialing. The hybrid workflow model ensures resourceful manpower, extensive healthcare expertise, and warrants the tedious work of aggressive follow ups, amongst other services, to be completed, all while away from your office. A virtual office genie can do all your work and increase your bottom line by up to 20%, all while reducing operational cost by as much as 30%. In order to survive the changes in the healthcare environment, medical groups can outsource various billing modules to third party solutions to maintain profitability. Off-shore labor power allows lowered operational costs and increases profitability instantly, putting medical groups in a lucrative space yet again. Don’t let your frustrations slow you down, Eligibility Verification solutions are here to stay.