Eligibility Verification - Everything You Need To Know

HEALTHCARE LANDSCAPE...

This is an area where practices are struggling to collect the revenue they are entitled to.

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.

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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SOLUTION TO IMPROVE

ELIGIBILITY CHECKING

One solution is to improve eligibility checking using the following best practices:


CHECK PATIENT ELIGIBILITYCheck patient eligibility 48 to 72 hours in advance of scheduled visits using one of these three methods:

Look up patient eligibility on payer websites.

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 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.

Method 1

Method 2

Method 3


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.


POTENTIAL PITFALLS

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.

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.


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:


BASIC STEPS

Patient Name Address/Number Identification DOB Obtaining the patient’s full name

directly from the card (photocopying/scanning is

recommended)

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.

Patient’s date of birth

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:


DEEP APPROACH...The increase in high deductible plans is making patients financially responsible for a larger percentage of a practice’s

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 patient’s benefits. Practices will need to gather additional information from payers during the eligibility verification process, such as:


Patient’s deductible amount and remaining deductible balance

Non-covered services, as defined under the patient’s policy

Maximum cap on certain treatments

Coordination of benefits

EFFECTIVE RESULTS

Outsourcing TasksPractices 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.

Financial Health

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 practice’s financial health.


EFFECTIVE RESULTS

Outsourcing TasksPractices 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.

Financial Health

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 practice’s financial health.
