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.


Eligibility Checking – The Necessity of Live Representative Calls to Payers

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.



Top 5 Overlooked Methods Proven to Increase the Efficiency, Accuracy of Eligibility Verifications

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.

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.

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.