Why Basic Eligibility Checks May Be Costing You

Sep 5, 2019 | Blog Article

Financially clearing patients is one of the most critical components of the revenue cycle. Money is made and lost there, before care is even delivered. And with patients changing insurance plans every 1-2 years, eligibility can no longer be just a ‘Yes or No’ question. You need to take benefit eligibility to the next level. 

Registration and benefit eligibility errors account for 23.9% of all denials.

Comprehensive eligibility calls are the lynchpin of every revenue cycle. You must check benefit eligibility throughout the entire care process, from scheduling services to submitting and remitting the claim.

One of the biggest challenges for healthcare organizations occurs when eligibility checks are performed during patient registration but aren’t rechecked prior to claim submission. That’s why it is important to have revenue cycle management (RCM) tools that allow you to identify and correct eligibility benefits in real-time throughout the care process. Because without those tools in place, you run the risk of denial due to a change in payer or plan coverage.

Failure to check and re-check eligibility could mean the difference between collecting a $25 copay or $625 out-of-pocket for something as straight-forward as an MRI or CT scan. 

A comprehensive and automated benefit eligibility solution increases reimbursements and revenue by showing you and your patients how their care will be covered before it’s provided, reducing the time your staff spends verifying eligibility. Moreover, it continuously checks for benefits throughout the entire claim process to ensure you’re applying the maximum benefit coverage.

But many providers are still handling eligibility verifications manually. 

A recent report from CAQH revealed that health plans field more than 72 million phone calls on benefit eligibility with each of those manual verification transactions costing $7.61. That’s more than 7 times greater than the average $1.09 cost of an electronic verification. 

This manual approach to eligibility leaves staff with the time-consuming process of checking eligibility by calling the payer or logging in to their website, directly affecting productivity, customer service, and employee morale.

When a patient initially makes contact with a medical provider, that should automatically trigger insurance eligibility verification. Front office staff should immediately collect the patient’s information and verify benefits across primary and secondary coverage for commercial and government plans. They should then continue checking benefits up until the claim is submitted to see if retro-eligibility benefits could be applied. But this doesn’t always happen, resulting in rejected claims. 

Eligibility verification software simplifies the billing process by providing real-time status on coverage, as well as handling co-pay, co-insurance, and deductible data, reducing errors associated with the manual entry of registration information and ensuring the accuracy of patient data.

Unfortunately, many current organizations aren’t prioritizing eligibility checks. Here’s how you can.

  • Plan benefits. Our ReconBots® add plan benefits to the EDI response only found on payer websites. We call this a super 271 EDI response. 
  • Intelligent payer communication. It’s no secret that payer responses are never the same within or across payers. Reco, the ReconBot, knows how to ask the right questions to a payer’s EDI and web infrastructure to discover all the important benefits. A service-type code of 30 for general benefits just doesn’t cut it for us. And you shouldn’t settle either.
  • Plan code validation and denial risk alerting. Using the detailed benefit information that our ReconBots secure, we are then able to identify anomalies in payer responses, indicating potential denials or inaccurate plan information. More than 35% of all registrations that trigger eligibility calls have some form of error that can (and probably will) manifest as a denial later on. Denial risk alerting puts a stop to that.
  • Data pull normalization. Our solution places all benefits into one place in the EDI response so you write less data pull rules. And because we track all of the payer changes throughout the year, you don’t have to modify rules when that happens. One rule equals one payer. Say goodbye to endless rule writing and rewriting.
  • Machine learning for pattern recognition. We look at remits to see what benefits payers are actually using to adjudicate, rather than just accepting what they say the benefit is in the response. This allows our benefit information to be more accurate than others. Our algorithms comb through hundreds of millions of records to discover patterns that no human could do on their own. 

The Wrap-Up. 

Simple ‘Yes or No’ eligibility checks are no longer the way to verify benefits. But neither is only checking benefits at the point of registration or every 3 or 4 years. It’s imperative to be continuously looking for the most comprehensive benefits a patient may be eligible for, and then re-checking their coverage throughout claim submission to apply the maximum benefit coverage.

See how you can get 3x more eligibility benefits with EligibilityPlus by Recondo.

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