In Part 1 of our hospital eligibility blog series, we looked at how to evaluate and improve your eligibility process. Part 2 explains the importance of back-end processes and helps you assess whether your back-end staff has the support it needs to succeed.
Does Your Back-End Process Need a Boost?
How do you treat your back-end revenue cycle management staff? Does it have the tools it needs to do its job properly, or is it just an afterthought to the organization’s front-end staff and processes?
Even if you think your intake staff does a thorough job of collecting patient info and verifying eligibility during the initial phone call or visit, your back-end staff still should play a big role in making sure your organization has all the information it needs to process patient claims. If your back-end staff has limited access to eligibility information and tools, it will be difficult for it to collect on claims with eligibility errors. And that isn’t good for your hospital’s bottom line.
Hospitals lose millions each year because of bad billing practices that lead to lost revenue. When a hospital leaks revenue, it can affect the entire organization, including patient care quality. One thing that can contribute to the problem is lack of coordination between front-end and back-end processes, according to a HIT Consultant article.
Front- vs. Back-End Processes
In healthcare, revenue cycle management is usually separated into front- and back-end processes. The front-end is patient-facing. Front-end staff handles scheduling, collects patient information, confirms insurance coverage and eligibility, registers new patients and collects patient payments.
Eligibility issues account for more claim denials and rejections than any other issue, according to Medical Group Management Association (MGMA).
Front-end staff must ensure that the services requested by the physician are covered by insurance. Its responsibilities include checking eligibility and sending and collecting signatures on forms such as Advance Beneficiary Notice or Notice of Non-Coverage before handing the patient over to the back-end staff. However, if services are not documented and coded properly at intake, Medicare will return or reject the claims, and that requires more work on the back end.
Collecting accurate patient information and verifying patient eligibility from the first contact is critical to both a healthy revenue cycle and a healthy bottom line. Eligibility issues account for more claim denials and rejections than any other issue, according to Medical Group Management Association (MGMA). Because of its importance, and the fact that eligibility information can change quickly, it must be checked during all points along the revenue cycle, from beginning to end. The key to proactively managing eligibility and claims is making front- and back-end processes part of a coordinated effort rather than two separate processes. Your front- and back-end staffs must share information and tools in order for your eligibility information and claims to be accurate.
Back-end staff may be tasked with other duties, from following up with patients to answering billing questions and collecting payment to submitting claims. Back-end staff also usually reviews previous eligibility requests to identify anything that was missed at intake. Checking and rechecking eligibility is important because the data is updated often.
Critical back-office functions for hospitals include:
- Customer service and patient pay
- System management and reporting
- Accounts receivable follow-up
- Credit balances and refund processing
- Claim submission and claim edit resolution
- Denial communications
Overlooking just one of these can spell trouble for a hospital’s overall financial health.
Back-End Tasks & Responsibilities
After a patient visit ends, the hospital’s back-end staff goes to work. One of the most important initial responsibilities is charge capture, or the process of turning services and physician time into billable charges. If the front-end staff hasn’t recorded clinical procedures correctly, it can result in inaccurate charge capture and lost revenue.
After the back-end staff establishes billable fees for the patient, it’s time to create and submit claims to payers. From ICD-10 and Healthcare Common Procedure Coding System (HCPCS) codes to patient data and health coverage information, staff must ensure each claim includes all necessary information before submitting it. Back-end staff must do this for many payers, and all the different payer requirements means that claim submission isn’t easy.
Back-end staff sometimes has to scrub submissions from claims that are less-than clean. It must verify clinical documentation and charge capture accuracy, ensure patient information is accurate and check that the correct codes are in place. Another task is reviewing rejected claims that come back and trying to correct and resubmit them. If your back-end staff doesn’t resubmit rejected claims or appeal denials, your organization can kiss a large portion of its reimbursements goodbye.
Revenue experts recommend making it standard practice for billing teams to prioritize rejected and denied claims and work on appealing or correcting and resubmitting them every day. This often falls on the back-end staff, which also has to make sure that payers correctly pay the hospital according to their contract.
Payer contract management is a key back-end function. Assessing payer performance and payment accuracy can help organizations negotiate better reimbursement rates and improve medical billing compliance.
Once claims are adjudicated, any remaining balance on a patient account should be sent to collections. Patient collections can be a major challenge for providers. According to McKinsey & Co.’s research, providers expect to collect between 50 and 70 percent of a patient’s balance after a visit. However, about 70 percent of providers reported that it takes a least a month to receive payments from their patients.
As back-end staff collects payments from payers and patients, it posts payments to the patient case, closes patient accounts and completes the revenue cycle.
Don’t Ignore Your Back-End Process
While the front- and back-end staffs manage very different parts of the revenue cycle, breaking down the siloes between the two can improve an organization’s bottom line. A hospital’s front and back office should work together to ensure revenue flows smoothly.
What happens when they don’t? Rebecca Wright, vice president of strategic planning at Iroquois Memorial Hospital in Illinois, told RevCycleIntelligence that the entire revenue cycle at her hospital has been a segmented process. She explained: “People only were familiar with their role whether it was registration or scheduling or billing.”
As a result, her staff suffered from a “lack of understanding on what the big picture was, including how patient responsibilities were calculated and what was actually needed to process a claim.”
By fostering collaboration between front- and back-office staffs, Wright said revenue cycle management became a smoother process and patient collections increased 300 percent.
So what are some things you can do to bolster your back-end process?
- Make sure back-end staff has full access to eligibility tools and software. Otherwise, it cannot easily correct or collect on claims with errors or incomplete data.
- If your organization employs several staff members to flag charge capture issues and fix those charges, you might consider another solution. Using software that trends charge capture data can make back-end revenue cycle processes easier and help shore up revenue leakage going forward.
- Your back-office staff should prioritize returned claims. If it doesn’t correct and resubmit rejected claims or appeal denials to recoup some of the reimbursement, your organization’s bottom line will suffer. About 90 percent of claim denials are preventable and can be corrected for payment, the Advisory Board reported. However, more than one-half of claim denials are never resubmitted.
The best way to improve your hospital’s reimbursement health is to get your entire staff on the same page working together, no matter which stage of the revenue cycle they specialize in.
How eSolutions Can Help Your Back-End Process
Eligibility errors account for more claim rejections and denials than any other issue. With our RCM tools, you can access complete eligibility data in real time without interrupting your workflow or creating unnecessary communication with patients, which may lower patient satisfaction scores. With eSolutions’ eligibility tools, you can:
- Quickly review previous eligibility requests to identify anything that was missed at intake
- Have on-demand access to run new eligibility requests from the claims corrections screen to avoid interruption of workflow by having to visit a different screen or service
- Access back-end eligibility tools
eSolutions’ tools quickly and easily connect to Medicare FISS/DDE and provide the best solution in the industry to submit and manage your hospital's Medicare claims. With our Medicare eligibility tool, there’s no need to manually check eligibility in HIQA.
For more information on our eligibility products, click here.