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.

How Hybrid Workflow Changed Our Practice: 10 Questions with Practice Administrator Nelly Gamboa

Credentialing ServicesClinicSpectrum: How long have you been using ClinicSpectrum?

Nelly: Union County Cardiology has been using the full suite for about 10 years now. We began using billing services and expanded the relationship to use credentialing and billing services.

CS: What do you like the most?

N:  That’s easy. I enjoy that I don’t even have to think about eligibility—all of our patients are confirmed to have insurance prior to their appointment, which considerably cuts down on A/R follow-up and denials management. My monthly headaches have been greatly reduced!

CS: What was the key factor to your decision to implement CS solutions?

N: Time is incredibly important. Saving time means getting paid and settling claims faster, allowing us more time to work on the most important part of the business, our patients. Anything that is proven to save me time is a winner in my book.

When we were doing entire process ourselves time was 30 minutes and cost was $8 to 10 per claim. With ClinicSpectrum, the cost of denials came down to $4 to $5 per claim.

CS: What are the 3 biggest challenges faced by physician’s practices?

N: While I wouldn’t have stayed in this career for so long if I truly didn’t enjoy, the fact is, like with any company, there are daily challenges that the team running a practice faces. From my perspective, I’d have to say that the three biggest challenges are managing efficient operations, staying up to date with all the changes necessitated by healthcare reform, and lastly, and in part linked to the changes in healthcare reform, is managing patient eligibility.

The good news is that there are solutions that greatly aid us in addressing these challenges. ClinicSpectrum’s hybrid workflow model lends itself to efficient operations, by coupling automation and outsourced human follow-up, allowing us to make the highest profit. At the same time, it’s my responsibility to be informed of all reform changes, which can affect every part of our business.

Profitability is hugely determined by adherence to the frequent healthcare reform mandates, so it’s imperative that someone in my position remains aware of all changes.

With automated eligibility, ClinicSpectrum saved us lot of surprises.

For example, eligibility has become a huge challenge due to healthcare reform. An influx of eligible patients, in addition to changes in health plan coverage for patients that were already insured, has left many practices scrambling. Knowing that a patient’s eligibility has been confirmed in advance allows us to secure payment easily and transparently.

CS: What has been the biggest aid for you in tackling these challenges?

N: By switching to automated eligibility verification, we save an average of $3,700 per year, per physician, and by submitting electronic claims rather than paper claims, we save an average of $23,126 per year, per physician, which helps us to still turn a profit and manage efficient operations.

Outsourcing claims and eligibility work is also a huge help in taking on these challenges. My team is able to oversee operations without having to spend the time to do the paperwork and follow-up as well.

CS: What were you looking for in an outsourcing company?

N: We had a few ideal attributes in mind when we began the search for an outsourcing company. We needed a company that could handle claims, authorizations and eligibility—we didn’t want to work with multiple vendors, so instead sought a one-stop-shop. Making sure the company is accountable and accessible is also a factor. Claims processing is often a 24/7 endeavor and I wanted to work with a company that I knew would take my calls and emails in a timely manner. Lastly, ClinicSpectrum’s hybrid workflow model of both automated and outsourced human follow-up offered something that its competitors didn’t deliver.

ClinicSpectrum offers all of these services and scrubs up the claims so minimal interaction is needed by my administrative staff, which allows us to spend valuable time with patients that would have otherwise been spent on administrative work.

CS: What are some challenges of outsourcing?

N: Our patient’s privacy is of the utmost importance to us and outsourcing can put that at risk. We prioritize that our patient data is safe and secure and that the company we outsource to remains HIPAA compliant.

Nelly Gamboa is administrator for Union County Cardiology Associates in Union, N.J.

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.