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Lower accounts receivable (A/R) days, higher collections, efficient scheduling and check-in -- that's the goal. In the meantime, as the front desk works hard to get a patient into the doctor's office, it is easy to see "efficiency" as "saving time." Skipping the eligibility verification, however, may not save as much time as one thinks -- and it adds time and labor later when billing needs to resubmit claims for reimbursement. What's more, important clinical decisions are often made based on what is covered by the patient's health insurance.
There are several points during the patient's experience when insurance can be verified. The most common points are 1.) during the initial call to make an appointment, and 2.) when the patient checks in. Verification is performed via a web portal or by calling the telephone numbers on the back of the patient's insurance card.
 How can I make eligibility verification less cumbersome?
To make eligibility verification -- and your revenue cycle - more efficient, you can have electronic eligibility verification built into your patient accounting system. Then, when the patient calls for an appointment, the registration staff member will send a query to your insurance company to determine whether the patient has valid coverage. A response will be received in less than a minute -- and usually just a few seconds. Most insurance companies will also send back lots of other valuable information, such as copay amounts, capitated services, whether a service is covered only with a particular vendor, etc.
That sounds great!
So why do so many claims have to be reworked by the people in the back office?
There are a lot of reasons that claims are rejected. Just because the patient's insurance company says he/she has coverage, it doesn't mean the information in the system is correct or that it matches what the insurance company has on file. It is pretty easy to make a mistake when typing in the information. Most insurance companies will provide a response if two of the three values are correct: Name, date of birth or member ID. However, a claim can be rejected for many reasons: incorrect subscriber ID, patient's name, if the patient is not the insured, patient's birthday, relationship of the patient to subscriber is wrong, the sex of either the patient or the subscriber, etc.
Why doesn't the scheduling staff member check to make sure the demographic information is correct?
In a perfect world, I'm sure the person scheduling patient appointments would check every single character on the insurance company's response, but let's think a minute about their job. The person making appointments is probably evaluated by how many patients they help a day, and they may be timed and rated on the average length of time it takes them to complete a call. Additionally, every insurance company may use a different format, so finding a particular value on a response can be difficult. Also, if a positive response is received, there is a reasonable expectation that everything is okay with the insurance. The front desk staff will also give the patient's registration the once over and do their best to make sure everything is correct, but with a full waiting room, checking every character on the registration is not always possible.
Can't the people in the back office clean up the claim before it goes out to the insurance company?
The answer is a resounding "yes." There are also claim vendors that scrub claims to detect errors and send them back to the billing office before sending the claim on to the insurance company. However, support staff and claim scrubbers can be quite expensive and add to the cost of healthcare.
Why are some claims still rejected or not paid as expected?
Unfortunately, many claims are still denied. For example, if a patient has a PPO plan but they were incorrectly registered with HMO, the insurance company will send back a positive response and the patient will be seen. The claim will probably even make it through the claim scrubber and get all the way to the payer who will send a payment. The problem is that the HMO plan is capitated and your patient accounting system adjudicated the claim and determined that no payment is due. When the payment is posted, it creates an overage in the system, which will have to be manually corrected.
Medicaid and Medicare patients often have supplemental coverage that should be selected as the primary coverage, with Medicaid and Medicare as secondary. If Medicaid or Medicare is primary, the claim will reject. Eligibility responses from Medicaid and Medicare contain information about supplemental coverage. So the eligibility response would be positive, because the patient is covered by Medicaid/Medicare, but a little more digging is required to discover the supplemental coverage.
We have a top-of-the-line, enterprise-wide system. Can't it compare the insurance company response to our registration record?
It probably can. Most integrated systems have logic that will do just that and give the user a warning, alerting them the data doesn't match. You can actually tell the user exactly what data element is in question, giving the user a prompt to ask a question. For example, the integrated system can alert the staff/user about a misspelled name, prompting a clarification question to the patient to correct it on the spot.
It could be that the insurance company has the wrong information on file. In that case, the patient needs to contact their insurance company and their employer to correct the information, or they may be financially liable. You should be able to put a note on the account and follow up with the patient a day or so before the appointment if you still can't get the insurance verified.
You can get a warning to the user that the patient has PPO coverage, not HMO. This will give the opportunity to correct the coverage and prevent incorrect adjudication, and may have an impact on clinical decisions.
If a family member is bringing an elderly parent to the hospital and they are unaware of supplemental coverage, the registrar will be alerted so the supplemental plan can be correctly registered as primary coverage and Medicare as secondary.
If the State has switched the supplemental plan of a patient on medical assistance, but the patient has not received the correspondence, the office will be prompted and the correct coverage will be selected. This saves a rejection from Medicaid and resubmission to the supplemental insurance.
Most systems will also prompt the user for the correct copay amount. Maybe that $20 doesn't sound like much, but it does add up. Beyond just adding up all of the $10, $15and $20 copays, think of the cost of uncollected copays. It leaves a balance on the patient's account, triggering a statement to be printed and mailed. The statement costs money plus postage. The patient will now have to write a check and mail it back. Someone will have to open the mail, post the payment and match it to the copay on the date of the visit. The cost of the uncollected copay could potentially be higher than the copay amount itself.
How much effort is involved in turning electronic eligibility on? Why wasn't it live before?
The setup and maintenance isn't simple. This may have been deemed out of scope for an initial go-live. It is usually considered an enhancement. You will have to be enrolled with insurance companies and contract with a third-party eligibility vendor. A network connection to the vendor will have to be set up, and you will have to test with each insurance plan to make sure the responses are what you expect. Performance is largely dependent on the insurance company and on your clearing house. The data on the response is always dependent on the payer. It is best to have a support specialist who is familiar with the intricacies of higher volume plans. On a positive note, once the initial enrollment and connectivity and testing are done, the hard part is over.
It doesn't sound as bad as cleaning everything up on the back end.
That is true. The effort to get the registration correct when the patient is in front of you or on the phone is much less than the effort to correct patient records after the fact. Electronic eligibility improves financial performance. One hospital reported a 75 percent reduction in claim edits the billing office staff had to correct. Patients and families will also enjoy a more pleasant experience and less time on the phone with customer service and insurance companies.
Raymond Boyd is an Epic-certified, senior consultant at Hayes Management Consulting, where he assists clients with revenue cycle optimization, system integration and the implementation of complex solutions for large healthcare organizations.
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