Obtain Accurate Patient Demographics
We sympathize. Your clinics are understaffed and your volume of patients is increasing. The priority is on the patient’s clinical care and the registration piece can be done anytime, right? Sometimes, as in emergent situations, it’s downright impossible to get any patient information, let alone accurate demographics. But for all the non-emergent visits, consider the importance of obtaining accurate registration information up front. According to the Ponemon Institute’s 2016 National Patient Misidentification Report, 30% of medical errors and 35% of all denied claims are the result of patient misidentification.
Have you established front end procedures on how and what information to ask the patient, and how to follow-up when it’s unattainable?
Some patients are unforthcoming with their personal information, and sometimes the patient representative doesn't ask thoroughly for information that has changed since the patient's last visit, or doesn't record the their answers accurately. Demographic information, such as middle initials or addresses, are easily glossed over, but their absence can make a big impact later in the revenue cycle.
erify Insurance Eligibility in Advance of the Patient Visit
Insurance eligibility is another crucial piece that is not being checked each and every time the patient comes for an appointment. Some organizations have policies flag the patient only once per year for a thorough registration. That may be convenient at the time of scheduling, but a lapsed or expired policy will create major inconveniences down the line.
Are you performing insurance verification for eligibility at each and every visit?
Use eligibility software to see if coverage is in effect for the current date of service, and also that the patient policy covers the procedure. In addition, verify if there is a need for pre-authorization in advance of the visit. If your patient representative is asking, “Is the insurance on file correct?” consider asking instead, “Do you still have [insurance plan]?” Patients are often unaware of changes to their plans until they receive a bill for a denied claim much later. That’s a real inconvenience for your patient who believed he or she was covered.
Obtain Pre-authorization and make sure it’s inclusive
Pre-authorization denials can be a headache on the front-end, partially due to a lack of standardization among payers. Developing processes and workflows by payer for the staff who need to submit the pre-authorization request is imperative.
Is there an administrative issue on the front end? Are key details of the medical record not being remitted?
First, focus on a handful of the most common payers in your region and train staff on the details the payer requires during their pre-authorization process. The biggest challenge is balancing patient expectations with payer expectations. If a patient believes they should be covered for a service, but their payer declines authorization due to something in the medical record, the burden of educating the patient about their financial responsibilty falls to the provider.
Second, check the number and frequency of claims denied for missing prior-authorizations and identify where the errors are originating, and which payers frequently deny.
Appeal denied claims and send corrected claims in order to increase payments
According to the recent revenue cycle survey from Advisory Board, there is a downward trend showing that denial appeals are less successful than ever before. On average, only 45% of appeals are successful with private payers, and only 41% are successful for Medicaid appeals. The good news is that Medicare and Medicare Advantage appeal success rates have actually increased over the past two years from 50% to 64%.
Do you currently appeal all denied claims? Is the cost to collect worth the effort?
Those might sound like obvious questions, but many organizations never bother with appeals due to the high cost to collect. The process of appeals is cumbersome (printing medical records, filling out corrected claim forms, mailing by snail mail, etc.) so it really might not be worth appealing low dollar claims, but you won’t know until you complete the legwork. Segment denial work queues by high dollar accounts and devise a work strategy for staff to send appeals on a pocket of claims with a similar denial code to increase efficiency in the process of collecting.