The Eligibility Verification Time Suck

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 Vishal-Gandhimore 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.

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How to create a delegated credentialing program?

Credentialing Services

This is part two of a two-part post that evaluates what is delegated credentialing and why healthcare provider organizations should consider it.

As explained in the first post of this two-part series, delegated credentialing is an opportunity for large provider organizations to take matters into their own hands, streamline processes and realize substantial benefits. These include getting providers credentialed quicker so they can generate revenue and expand clinical bandwidth.

So, how do organizations create a delegated credentialing services process? It entails establishing processes, as well as implementing tools to assist with workflow and manage the flow of data.

Key processes to implement include:

  • Adopting Credentialing Standards — The National Committee for Quality Assurance (NCQA) has already established standards for payers, as has the Joint Commission for providers. Standards from both organizations should be adopted, as well as any specific standards from regional payers.
  • Establish a Review Process — Create a committee to define processes and review provider credentialing.
  • Conduct Ongoing Monitor — Develop processes to continually monitor work quality.
  • Re-Credentialing — Create processes to easily re-credential providers on an ongoing basis.
  • Create Agreements with Payers — Delegated credentialing agreements need to be established, clearly stating structure and metrics, including:
    • Outlining the responsibilities of the payer and delegated entity.
    • Detailing metrics of how the payer can define and assess performance.
    • Developing ongoing oversight processes.

Accomplishing these processes requires sophisticated credentialing software that includes:

  • Analytics and reporting
  • Dashboard presentations and milestone tracking
  • Demographic import features
  • Document management
  • Reminders and notifications
  • Task management and assignment features

A key resource to assist with delegated credentialing programs is the Healthcare Billing and Management Association (HBMA). The organization has a number of useful resources that expound on the above in further detail.

Author Julia Solooki is a board member of the HBMA Education Committee.

Show Me The Money

“Show me the money!” The famous phrase uttered by Tom Cruise in his role as Jerry Maguire, the fast talking sports agent in the 1996 hit film, has been echoed countless times. And when it comes to running your medical practice, seeing the money is an absolute necessity. You provide services to your patients, and you need to collect for them.

All too frequently practices pull their aging reports and 30,60,90—even 120 days out, there are unpaid claims. When added together, these claims are costing practices tens of thousands of dollars. On top of recouping these payments, then there is also the extra legwork that goes into denials management.

It’s inevitable that you don’t have a 100% clean claims ratio. It’s virtually impossible due to the fact that claims can be rejected for any number of reasons, ranging from lack of pre-certification or prior authorization, to diagnosis and procedure coding errors and omissions, to complicated workers’ compensation issues. In fact, according to the AARP, 200 million claims are rejected every year, and 60 percent are never resubmitted, resulting in a financial loss for the practice.

Imagine this:

– Shorter collection time

– Your staff freed for other office activities

– More money collected

It’s a reality. We can show you the money. Why continue to suffer with the burden of difficult-to-manage accounts receivable when you can rely on an outsourced staff that is tenacious and will relentlessly work to recoup your hard earned dollars. It costs $25 to $30 for you to manage the average denial, according to the Medical Group Management Association (MGMA). For a fraction of that cost, a devoted, experienced team can follow-up on your report. And in the event of the claims denials, our experts won’t stop till they have identified the reason for the denial, helped correct the issue, and gotten you your money—faster.

Clinicspectrum is a healthcare services company providing outsourcing/back office and technology solutions for 17+ medical billing companies, 600+ medical groups/healthcare facilities including hospitals, and hospital medical records departments.

Outsourcing Provider Credentialing = Gaining Specialization

It makes so much sense that doctors do this all the time. So, why then, isn’t it best practice to provide specialization for the critical tasks in physician offices, such as provider credentialing? It seems as if such a necessary task so vital to protecting a practice doesn’t get the respect or staff resources that it deserves. Instead, credentialing work is simply absorbed by various members of the back-office staff. As a result, the accuracy of credentialing work is often compromised, exposing the organization to financial and patient safety risks.

But rest assured, credentialing specialization does exist, and can be obtained. The answer: Outsourcing. By outsourcing an organization’s credentialing function, physician offices can better focus their staff on revenue-generating tasks, such as billing and collections.

A primary benefit of outsourcing is that it allows provider organizations to access industry-leading expertise on the nuances of physician credentialing, enabling them to get the work done, quicker, better, faster. Experienced credentialing professionals have spent years learning about information resources to verify credentials, which helps them avoid potential pitfalls, and enhance their work through best practices.

Working in harmony: It’s important to note that outsourcing doesn’t necessarily mean that provider organizations have to completely relinquish their control over the function. Rely on the specialization, while keeping the tasks that are easier to manage within the office. This also keeps costs in check. For instance, many organizations choose to retain control over certain aspects, while outsourcing the labor-intensive processes of conducting background and reference checks, or the tedious processes of verifying schools, licensure, employment, malpractice carriers, and more. Experienced outsourcing professionals have the tools, resources and knowledge to perform these tasks faster and more accurately.

With the right outsourcing arrangement and leveraging specialized experts, organizations can remain better focused on their core competencies to improve performance and profitability.

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.

Automate to Collect patient balances

Out of sight, out of mind. Applied to healthcare, this age-old saying is not only true, but also incredibly problematic for physician practices. All too frequently we hear from physicians the same story of providing care up-front, and subsequently facing a growing stack of un-paid deductibles, ultimately hurting the bottom line. No one is immune to this – not general practitioners, specialists, psychologists, nor dentists.

With the trend of increasing deductibles, there is only going to be more to collect. For 2014, the internal revenue service has defined high-deductible as $1250 for an individual and $2500 for a family. On top of that, maximum out-of-pocket expenditures are estimated at $6350 for individuals and $12,700 for families. That’s no small change; that’s real money when factoring in the number of patients you see.

Some practices may have an initial reaction of fear or a sense of alarm from these numbers however, these statistics should be the impetus to be proactive and put the right series of steps and technologies into place. Those steps include implementing a hybrid workflow model that starts with using an established eligibility checking system to identify a patient’s expected out-of-pocket costs prior to an appointment will significantly lessen the follow-up collections that are needed. However, when you do need to collect, make sure you are doing it smartly by leveraging the second piece of a hybrid workflow solution, an automated collection system to significantly increase the odds that you will collect more, and also collect it faster.

Recent highlights from the Pew Research Internet Project state that as of January 2014, 58% of adult Americans have a smartphone.  Doesn’t it make sense then that you should have an automated system that includes texting alerts instead of sending outdated hard copy letters? By replacing traditional collection methods with an automated technology platform that smartly uses decision rules to push out text and secure e-mail, and logs a record of all the activity, you can count your profits instead of counting the number of uncollected deductibles.

Credentialing. There’s no Easy Button for that.

17Staples has its now famous “Easy button” which designates how easy it is to get things done with them. There are countless apps for nearly every process and experience you can think of, adding ease of use and simplification. Then there is physician credentialing. What was once a simpler process that previously included the single step of having the applicant present some form of documentation, such as a diploma or certificate, is now much more complicated.

Multiple forms. Credentialing today requires school, residency and licensing verification directly from the source of the diploma, license, etc. Thorough and legitimate collection and verification of this information is not only important in meeting requirements of main accreditors, but also critical in avoiding legal problems and ensuring quality patient care.

Many people. The lengthy and increasingly complicated process of credentialing requires input from multiple people serving in specific roles. Almost like a set of dominos, if one of these roles is not fulfilled correctly and in a timely manner, the entire process could crumble or cause major headaches.

Myriad steps. From the applicant’s responsibility to provide a clinical facility with supporting paperwork such as degrees, accreditations and licenses, to medical staff’s responsibility to process and maintain the applicant’s credentialing file, there are a lot of steps and paperwork to keep track of. In departmentalized hospitals, the Department Chair also plays an important role in reviewing credentialing files. A credentialing committee, medical executive committee and governing board of directors also play important roles in the process as applicable to the specific facility.

If you’ve been through it just once, you know exactly what I’m talking about. While each hospital and physician’s office have their own individual challenges, a thorough and valid credentialing process is no less imperative. Healthcare facilities can benefit greatly from knowledgeable staff that is thoroughly trained to handle time consuming credentialing process and focus on nothing but making sure it is getting done right. Remove the possibility of one of the “dominos” falling in the credentialing process, and outsource to a company that can cover everything from A to Z. It’s not technically an “Easy Button,” but it’s the easy and obvious solution.