Insurance Eligibility Concerns

Overall, the healthcare revenue cycle is an extremely complex and crucial process for generating reliable medical billing revenue. Health insurance verification is one of the key initial steps in the revenue cycle, it is important to understand that any errors at this point can have adverse effects on the facility's or provider's billing revenue.

Many studies over the past several years have demonstrated that administrative expenses like billing and coding, insurance administrative costs, and physician administrative activities account for up to 25% of total national health care expenditures (JAMA).

Cost improvements like reducing medical billing errors and adopting health insurance verification software or tools can help reduce expenses and drive revenue for providers, medical facilities, DME suppliers, Ambulance services and many others.

Recent Studies show that healthcare providers spent an average of 30% of their annual income in the insurance verification process.
What is the insurance verification process?

The key purpose of the insurance verification process is to ensure claims can be submitted for medical procedure, and to ensure patients are eligible for coverage.

Not performing this crucial step can and will result in unpaid or denied claims which becomes an unnecessary financial burden on your patients. Verification prior to service can and will eliminate these revenue concerns that ultimately cost healthcare providers a lot of money, time and resources.

Eligibility Verification Process
  1. Receiving patient demographic information

    Step one of the processes is to gather relevant and accurate patient demographic information from a referral reference source (like a hospital) or the patient directly. This ensures all future documentation is filled out accurately.

  2. Verify the patient information with the insurance carriers

    Next step is getting information from the insurer, including:

    • Payable benefits
    • Co-pays
    • Co-insurance amounts
    • Out-of-pocket maximums
    • Deductibles
    • Policy status
    • Date policy went into effect
    • Date policy ends
    • Plan exclusions
    • Type of plan (HMO, PPO, EPO, etc.)
    • Claims mailing address
    • Referrals
    • Pre-authorization
    • Other coverage details

  3. Confirming coverage on both primary and secondary payers

    Many patients have more than one insurance plan. One would be identified as the primary while the other acts as the secondary policy and another could even be tertiary. Hospitals, Clinics, Providers, etc. all must be careful to correctly identify which insurance policy needs to be billed.

    NOTE: Failing to bill properly can result in more than just lost financials issues, but can cause legal problems as well (and no healthcare professional wants to deal with that).

  4. Accurately prepared documentation

    It's crucial that administrative staff verify all patient data is entered into their record with precise accuracy to prevent any errors or delays with claims and payments. IMPORTANT! What seems to be minor discrepancies can have severe consequences for timely reimbursement.

    The Eligibility verification process is critical during multiple points of the revenue cycle, from the initial appointment scheduling to post-appointment billing and management. Any missteps can financially impact the provider and facility.

    Understanding how to properly process Eligibility Verifications and when to run can greatly increase revenues, just by submitting better data and understanding what is needed to be sent and how to properly use the data that is being returned.

Failed Eligibility: Eligibility Verification errors that can affect your revenue!

We all know that insurance verification systems are essential to the revenue life cycle. What everyone may not realize yet is by identifying common problems Hapogy LLC. Can help organizations like yours to determine where they might need cleaned data, updated reference materials or even an automated solution.

NOTE: An automated solution can help prevent revenue loss in paid claims and in time spent handling billing issues by staff members and processes can be put in place to assist pre submission, post submission or both. Below you will find a list some of the most common errors that can cause issues and may need to be addressed.

  1. Wrong patient information

    Capturing accurate information into the patient's billing profile and medical record is vital to submit a successful Insurance Verification or Claim request. The Insurance Verification and Medical Claims depend on accurate, correct data, and even a single wrong number, space, dash or even misspelling could result in a not found verification or could even turn into a costly denial.

    Administrative staff should be trained and educated on the importance of medical billing errors and patient rights. What just may seem like an Error can have a significant impact on your practice and reputation, which can potentially lead to HIPAA violations and even fines.

  2. Inactive insurance policies

    Patients having inactive insurance policies are one of the most common reasons for claim rejections. We offer low cost, no commitment options for insurance verification to help, as we realize that costs add up and we want to allow everyone to process Insurance as much as needed without worrying about cost. The most efficient way to deal with this problem is to check eligibility prior to service being provided to ensure coverage, but when you work with us, uou can run verification whenever it is needed.

  3. Neglecting to ask about a secondary policy

    Some patients have more than one active health insurance policy for many reasons. One policy would be the primary, and the other is designated as the secondary policy. During eligibility checks, staff members need to ask about any secondary coverage to ensure billing is handled correctly.

    This responsibility can be a little time-consuming when a facility or clinic's admin staff is short staffed and already have multiple obligations to complete all at once, which is why an automated system can almost fully eliminate failed eligibility.

  4. Failure to get a copy of the patient's insurance card

    Even if the patient provides details over the phone or information is obtained in person, it's not uncommon for inaccuracies to occur. Always make a copy of both sides of the insurance card so you have it on hand to refer to if needed.

  5. Failure to properly verify patient is eligible for Skilled Nursing Facility (SNF) coverage

    Billing errors and failure to verify SNF eligibility properly can result in large overall costs to a facility. There are rules that state a patient is required to have a 3-day consecutive inpatient stay at a hospital before being eligible for a skilled nursing facility. Even small errors and omissions in both the health record and billing information may have a significant effect on reimbursement from CMS. Let Hapogy LLC. Create flags and systematic alerts that can help reduce loses caused by improper SNF validations.

Why checking patient eligibility before services is important

Insurance verification process can have positive benefits for any practice or healthcare facility, including:

  • Reduce the number of claim denials
  • Avoid inaccurate billing
  • Avoid HIPAA violations
  • Reduce the late or missed payments from patients.
Crucial factors that influence why insurance verification is a significant issue for healthcare organizations
  • Staff rely on manual processes like performing data entry and making physical copies of insurance cards, all while interacting with patients in person and over the phone. These confounding factors make data omission almost impossible to circumvent.
  • The crucial step of entering accurate information into the billing system and patient record is performed by an administrative staff that is typically the lowest paid and have the highest turnover. There is hardly an incentive for overworked employees to perform monotonous and tedious tasks that take away from personal interaction with patients.
Benefits of real-time eligibility
  • Administrative employees can shift away from time-consuming phone and fax communication and get RTE query results in minutes
  • Reduce claim denial rates
  • Streamline the revenue life cycle
  • Increase revenue for your medical office or facility
  • Increase patient satisfaction and retention
  • Minimize billing errors and missed payments
  • Execute a smoother eligibility verification process
How automation can eliminate eligibility verification errors

According to industry reports, one in three healthcare executives say that denied claims happen about 10%-15% of the time, resulting in billions of dollars in lost revenue. Using an automated medical insurance verification system like what Hapogy LLC. Offers can help eliminate the vulnerabilities of manual patient eligibility verification and pay big dividends across the revenue cycle. It is important that not only does automation help relieve the manual burden placed on staff, but that it also improves operational efficiency, ensures cleaner claim submissions, speeds up reimbursement, reduces medical billing errors and creates a better patient experience overall.

Here's how:

  1. Integration with office software systems

    To keep things running as smoothly as possible, providers should consider automation eligibility tools that integrate seamlessly with their existing systems and interfaces. This can help fully leverage data analytics and streamline operations. Integrating automated solutions with health records can also speed up verification and registration.

  2. Real-time connections with major insurance carriers

    Using insurance verification software can help keep patient insurance information up-to-date. For example, Hapogy's solution connects with over 900 payers instantly or we will help each individual establish direct connections to any specifc payers that would improve outcomes.

  3. The ability to calculate a patient's estimated payments

    Inconsistencies between estimated and actual costs are common patient complaints. By providing estimates upfront, providers can reduce this major concern. Automating pre-service eligibility and estimates provides patients with a clear view of their financial obligations so they can plan accordingly.

Prevent eligibility verification errors to get paid faster!

Insurance verification is an often underestimated, yet crucial component of the patient experience. Automating or at least updating this process with advanced data analytics can help minimize denied claims and long-term financial losses while strengthening trust between patients and providers. Overall, correcting and updating insurance verification early on has the potential of huge benefits throughout a provider's revenue cycle.