ELIGIBILITY VERIFICATION WITH PAYERS

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ELIGIBILITY CHECKING
Everything you need is covered in this
presentation, to make viewing worth watching and
improve your productivity.
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HEALTHCARE LANDSCAPE...
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 to.
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 impacting cash flow
and profitability.
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One solution is to improve eligibility checking
using the following best practices
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CHECK PATIENT ELIGIBILITY
Check patient eligibility 48 to 72 hours in
advance of scheduled visits 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.
Method 1
Method 1
Look up patient eligibility on payer websites.
Method 2
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
center. Clearinghouses do not provide these
details, so calling the payer is necessary for
these scenarios.
Method 3
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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 theyll need to pay
and when.
Determine co-pays and collect before service
delivery.
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POTENTIAL PITFALLS
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, its
because it is. This isnt 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.
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TAKING PROACTIVE APPROACH
More than 20 percent of claim denials from
private insurers are the result of eligibility
issues, according to the American Medical
Association. To reduce these types of denials,
practices can employ two proactive approaches
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BASIC STEPS
Many eligibility issues that result in claim
denials are a result of simple administrative
mistakes. Practices must have comprehensive
processes in place to capture the necessary
patient information, store it, and organize it
for easy retrieval. These include
Address/Number
Identification
DOB
Patient Name
Patient address and phone number
Obtaining the name and identification numbers of
other insurance (e.g., Medicare or other type of
insurance plan involved). Again,
photocopying/scanning of all health insurance
cards is recommended.
Patients date of birth
Obtaining the patients full name directly from
the card (photocopying/scanning is recommended)
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DEEP APPROACH...
The increase in high deductible plans is making
patients financially responsible for a larger
percentage of a practices revenue. Therefore,
practices need to know their financial risks in
advance and counsel patients on their financial
obligations to improve collections. To accomplish
this, practices need to look beyond whether or
not the patient is eligible, and determine the
extent of the patients benefits. Practices will
need to gather additional information from payers
during the eligibility verification process, such
as
Patients deductible amount and remaining
deductible balance
Non-covered services, as defined under the
patients policy
Maximum cap on certain treatments
Coordination of benefits
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EFFECTIVE RESULTS
Outsourcing Tasks
Practices which take a proactive approach to
eligibility verification can reduce claim
denials, improve collections, and reduce
financial risks. Practices that do not have the
resources to accomplish these tasks in house may
want to consider outsourcing specific tasks to an
experienced firm.
Implementing these proactive eligibility
approaches is important, whether practices handle
them in house or outsource them, since denials
resulting from eligibility issues directly impact
cash flow and a practices financial health.
Financial Health
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ABOUT US
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CONTACT US
https//www.linkedin.com/company/clinicspectrum-in
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https//www.youtube.com/Clinicspectrum
Clinicspectrum is a healthcare services company
providing outsourcing and back office solutions
for medical billing companies, medical offices,
hospital billing departments, and hospital
medical records departments.
Email info_at_Clinicspectrum.com
Website http//clinicspectrum.com/
2222 Morris Ave. 2nd Floor,Union, NJ-07083
Phone Number 908.834.1608