For healthcare providers, claim denials are just a routine part of business. It seems you can’t completely escape them no matter how hard you try. You’ve heard the statistics: The average claim denial rate across the healthcare industry falls between five and 10 percent, according to an American Academy of Family Physicians (AAFP) report.
In 2016 alone, 37 million out of 448 million requests – either for prior approval of services (24 million) or for payments of services already provided (424 million) – were denied, according to a 2018 study from the Office of Inspector General (OIG) of the U.S. Department of Health & Human Services. Thirty-six million claims were rejected due to non-payments or underpayments for services rendered, while one million were prior authorization denials.
While there’s no quick fix to the problem, it is true that about 90 percent of claim denials are preventable, according to a 2014 Advisory Board study. In fact, most claims are denied for avoidable mistakes such as incorrect patient identifier information or missing patient demographic and insurance information. Even if all their information is correct, patients are not always aware of coverage changes or termination.
You can’t prevent every claim denial, but you can reduce them by strengthening your hospital eligibility processes. The success or failure of the patient claim game begins and ends with your intake process.
An efficient, proactive intake process will ensure patient and insurance data are accurately collected and reported before or at the point of service. Getting the most accurate patient information upfront begins at scheduling and registration.
Patient insurance eligibility verification is the first – and possibly most important – step in the intake and the entire billing process. Your front line staff has to be on top of their game to collect and accurately record all eligibility information from each and every patient. And when hospital staff can access instant eligibility information, both patients and providers benefit.
Equally as critical as collecting the correct patient information is identifying the appropriate payers at intake to avoid delays or reimbursement losses. Is the patient covered by Medicare A or B, or is the patient covered by a private insurer and a Medicare Secondary Payer or Medicare Advantage plan? Intake staff must check each patient’s secondary or supplemental payers for eligibility to make sure the hospital has a complete eligibility profile so charges won’t get sent to patient collections unnecessarily.
Medicare Advantage plans now cover more than 20 million people — more than one-third of all Medicare beneficiaries, and continue to grow, according to The New York Times. Federal officials predict that enrollment in Medicare Advantage plans will climb next year to 22.6 million, or 36 percent of beneficiaries. The total number of people covered by Medicare is expected to reach 72 million by 2025, up from 60 million today. Advantage plans have higher denial rates than the traditional Medicare plans, according to an OIG report.
Here are three ways providers can ensure you’re at the top of your game when it comes to the patient intake process:
1. Take advantage of technology
Before and after a patient arrives, leverage technology to make the intake process more efficient. Send patients information about billing, insurance, scheduled appointments and follow-up care through email or text messages. Ask for information before the appointment, including which Medicare plan a patient is covered by, secondary payer information, benefits cap, where to send the claim, whether the payer requires authorization, special forms or documentation. Getting to the hospital for care and having to spend 15-30 minutes filling out forms on insurance, medical history and demographic details can be frustrating for patients, too. Add to that HIPAA regulations that require consent and re-verification of patient information and the process can be exhausting for both patients and medical professionals. Gathering this information beforehand relieves patient anxiety and allows your staff to focus more of its time on other important functions, such as patient care.
2. E-forms and e-signatures complement EHRs
Forms are the lifeblood of every healthcare organization. They must be complete and easily accessible. You can implement an EHR system, but you may not save much time or efficiency unless you move to e-forms as well. E-forms are essential for collecting and sharing data effectively. Manually scanning forms into each patient’s EHR results in errors and lost productivity. A dedicated e-forms system will complement your EHR system. It will enable you to instantly archive documents in the EHR and give staff a better way to capture, store and share data. E-signatures save time, money and automatically link to the patient record and e-form content stored inside an ECM system or shared with other applications. Also important, they can make the intake process much faster because patients can fill them out from the comfort of their own homes before they arrive at the hospital.
3. Automate here, there, everywhere
Providers want their staff to focus most of their time on patient care. That’s why we’re all here, right? The intake process will be much easier for providers and patients if it’s automated as much as possible, starting with checking a patient’s eligibility. A web-based tool that allows providers to check and verify eligibility in a real-time manner and get access to the most current coverage information for each patient can be invaluable in a busy hospital. Beyond a basic eligibility check, having a complete Medicare eligibility profile for each patient that is accessible to all staff can save time for everyone and reduce providers’ claim denials. Reducing eligibility confusion is critical considering that ineligible patient insurance coverage is one of the top reasons for claim rejections and denials by payers. To avoid claim problems, it’s important to know whether a patient is covered before providing services. With an automated system for verifying eligibility, you can avoid common billing mistakes and decrease registration errors, which in turn reduces rejected and denied claims.
Your intake process is your first and most important line of defense against claim denials. An effective intake process literally can mean the difference between getting reimbursed for medical services provided – or not. So you want to make sure it’s as thorough and accurate as possible. If you have a complete eligibility profile for each patient that is accessible to all staff throughout the revenue cycle management process, you’ll reduce your claim denial rate and the entire process will be less stressful for both patient and provider.
Our Medicare Enterprise package is the most efficient RCM solution on the market. From checking eligibility to evaluating claim data and even working claims in RTP, this is a serious end-to-end solution that takes your claims through the entire reimbursement process. eSolutions’ Multi-Payer Eligibility provides secure access to multiple health plans, including MA, so you can check eligibility and benefits in real-time from a single, convenient web-based tool. With a feature unique to Multi-Payer Eligibility, you can discover all your patients’ coverage at once with our new cascading search capabilities. In one step, you can search for coverage from multiple payers, including Medicare, Medicaid and commercial payers.
Determining eligibility at intake is important, but it’s just the beginning. It’s also critical for follow-up staff to have access to back-end eligibility tools. Find out why in Improving Your Hospital Intake Game — Part 2.
Why Is Hospital Eligibility So Important?
- Verifies reimbursement will eventually happen
- Paints a picture of the patient’s healthcare status
- Sets the course for accurate billing (Secondary payers are increasing.)
- Provides historical data to prepare you for post-adjudication