Navigating today’s dynamic healthcare billing and reimbursement climate can throw costly challenges at providers and their busy billing teams. Challenges like capturing accurate insurance data, timely claim submission, managing claim denials and rejections, handling review requests and audits. These issues and more contribute to reaching your number one goal of reducing days in A/R and getting more cash through the door.
In this weekly blog series, we’ll break the reimbursement cycle down into three steps and show you how smart, simple changes to your processes arm you to tackle even the greatest challenges. In the next few weeks, we’ll dive deeper into strengthening these three key reimbursement stages so your team can bill well and prosper:
- Determining Eligibility
- Claims Submission
- Claims Management and Business Intelligence
Step 1: Eligibility Verification
Determining patient eligibility and coverage data is essential for successful claim acceptance rates and ultimately reimbursement from Medicare, Medicaid and commercial payers. Not only is front-end coverage determination critical, performing additional verification on reoccurring patients will help alert you to coverage changes that would otherwise cause claim adjudication challenges, including potential denials.
Up-Front Patient Eligibility Verification
Up-front patient eligibility verification lays the foundation for your entire revenue cycle process. Since eligibility errors create more reimbursement challenges than any other claim issue, the importance of this step cannot be overstated.
Because patient insurance information can change overnight, you may choose to verify eligibility when appointments are scheduled, again right before an appointment, at patient check-in and even after the appointment.
When determining eligibility, you should identify the following:
- Beneficiary and subscriber verification
- Eligibility and benefits
- Coverage type
- Deductible data
- Provider/service specific coverage information:
- Preventative services
- Cap or threshold amounts
- Hospice information
- PPS episode information
- Coverage changes since prior inquiry
If you’re still checking eligibility manually or if verification hinders your billing efforts, consider implementing eligibility technology that dramatically eases this step. Today’s technology allows you to accomplish instantly what once took significant effort to perform manually.
Many providers choose to retrieve patient eligibility data direct from the payer websites. This highly manual process costs you and your team time and money. This step becomes a must, however, because many eligibility providers don’t deliver the necessary data. You can eliminate this manual effort by choosing the right eligibility verification system. More advanced systems will automate the process of retrieving data directly from the payer websites, significantly enhancing the data you receive in your eligibility reporting. By capturing and comparing even more personal patient data and coverage information, advanced eligibility has the potential to exponentially improve workflow and output.
Identifying Coverage Changes
Tracking patient coverage changes requires a process to regularly check eligibility. Any provider who sees reoccurring patients will likely realize better reimbursement rates by performing monthly verification.
Regularly scheduled batch eligibility verification at the right time uncovers data that allows you to proactively reveal discrepancies in patient coverage.
Look for red flags like changes in Medicare Advantage Plan enrollment, deductibles, preventative services, prior episodes with another provider, etc.
During Medicare’s Open Enrollment period, it’s highly advantageous to run a batch submission including every patient you’ve seen the past 12 months to expose coverage changes that are costly if unnoticed.
Leveraging an eligibility technology vendor with automated change reporting capabilities will eliminate the hassle of manually sifting through heaps of patient data to detect eligibility changes. A vendor with advanced eligibility verification will report only those patients who show coverage changes.
Coverage discovery lets your front office team find patient eligibility for government and commercial coverage that may be missing or unknown during patient registration.
When patients lack coverage, oftentimes the unfortunate reality is they can’t pay. Adding an automated coverage discovery tool to your process boosts the chances of securing payment for care that may otherwise go uncompensated.
Adding an automated coverage discovery tool to your process boosts the chances of securing payment for care that may otherwise go uncompensated.
The payoff of a solid eligibility process is positive cash flow, less rejections and denials and a more efficient staff. Using a vendor like eSolutions for advanced eligibility improves workflow automation and reduces labor costs and days in A/R. Next week, we’ll examine ways to improve your claims submission processes.