First Pst after migration to Cloud in Health care Blog

More than 13 million Americans have lost Medicaid coverage since continuous enrollment came to an end in April 2023. Unwinding the emergency provisions requires states to determine which individuals remain eligible for Medicaid, leading to widespread disenrollment. The Medicaid redetermination process created a major admin burden for agencies and providers, and now, the impact of that burden on patients has become clear: more than 7 million of those who lost coverage were disenrolled because of administrative processes, and not due to ineligibility. While some will find coverage elsewhere, many will be left without insurance. These coverage gaps disrupt health services with adverse effects for patients and providers. In a recent webinar, Kate Ankumah and Mindy Pankoke, Product Managers at Experian Health, reflect on the Medicaid redetermination process and discuss how providers can mitigate the effects of redetermination heading into 2024. Recap: Medicaid continuous enrollment provision timeline How does the Medicaid redetermination process work? The redetermination process, led by state agencies, involves reviewing Medicaid rosters and automatically renewing coverage for individuals that still qualify, based on benefits or other government data. When coverage cannot be confirmed automatically, states need to reach out to patients to fill in the gaps. If the individual is no longer eligible (or does not provide the necessary data), they will be removed from coverage lists. Many patients are confused about the process and may not even realize they're no longer covered, leading to delays and distress when they try to access care. This blog post breaks down the 5 things providers can do if a patient loses Medicaid coverage. 1. Tighten up insurance eligibility verification processes During the webinar discussion, Kate Ankumah explains that implementing a reliable eligibility verification tool is essential to reduce financial risk, increase revenue and streamline staff workflows: “With our Eligibility product, we connect to more than 900 payers with search optimization. Providers don't need to send the same information over and over – we'll run through the search options ourselves and find the information as quickly as possible. Then we standardize the data so front desk staff can read all the responses in the same way. We also build in alerts. A couple of clients have alerts set up for Medicaid redetermination dates that pop up if a patient is due for redetermination so the front desk staff know to have a conversation with them about it.” Eligibility also includes an optional Medicare beneficiary identifier (MBI) lookup service, to check if any patients who may have been disenrolled from Medicaid are now eligible for Medicare. 2. Find missing coverage with Coverage Discovery Providers may also want to automate the search for any active coverage that may have been overlooked. Coverage Discovery searches for possible billable government or commercial insurance to eliminate unnecessary write-offs and give patients peace of mind. Using advanced search heuristics, millions of data points and powerful confidence scoring, this tool checks for coverage across the entire patient journey. If the patient's status changes, their bill won't be sent to the wrong place. In 2021, Coverage Discovery identified previously unknown billable coverage in more than 27.5% of self-pay accounts, preventing billions of dollars from being written off. 3. Quickly identify patients who may be eligible for Medicaid and financial assistance The lack of clarity around enrollment and eligibility is disruptive for claims and collections teams. How can they handle reimbursements and billing efficiently if financial responsibility is unclear? Denial rates are already a top concern for providers, and staff cannot afford to waste time seeking Medicaid reimbursement for disenrolled patients. Patient collections also take a hit when accounts are wrongly designated as self-pay. With Patient Financial Clearance, providers can quickly determine if patients are likely to qualify for financial support, then assign them to the right financial pathway, using pre- and post-service checks. Self-pay patients can be screened for Medicaid eligibility before treatment or at the point of service, and then routed to the Medicaid Enrollment team or auto-enrolled as charity care if appropriate. Post-visit, the tool evaluates payment risk to determine the most suitable collection policy for those with an amount to pay and can set up customized payment plans based on the patient's ability to pay. Patient Financial Clearance also runs back-end checks to catch patients who have already been sent a bill but may qualify for Medicaid or provider charity programs. This helps secure reimbursement and means patients are less likely to be chased for bills they can't pay. 4. Screen and segment patients according to their propensity to pay Optimizing collections processes is always a smart move for providers, but particularly now that federal support has ended. Collections Optimization Manager uses advanced analytics to segment patient accounts based on propensity to pay and send them to the appropriate collections team. Drawing on Experian's consumer credit data, Collections Optimization Manager's segmentation models are powered by robust and proprietary algorithms. These models screen out Medicaid and charity eligibility, so collections staff focus their time on the right accounts. Case study: See how University of California San Diego Health (UCSDH) increased collections from around $6 million to over $21 million in just two years using Collections Optimization Manager. 5. Make it simpler for patients to manage and pay bills The reality is that many patients affected by the unwinding of continuous enrollment will be on low incomes. When more than half of patients say they'd struggle to pay an unexpected medical bill of $500, providers should make it easier for patients to gauge their upcoming bills. Patient Financial Advisor and PatientSimple® can help patients navigate the payment process with pre-service estimates, access to payment plans and convenient payment methods they can access on a computer or mobile device. Together, these tools can help providers manage Medicaid changes efficiently and offer extra support to patients who may be facing disenrollment. Watch the webinar to see the full discussion on how Medicaid redetermination is affecting providers and find out how Experian Health's digital solutions can help healthcare organizations quickly and easily verify insurance coverage.

For many Americans, access to healthcare is increasingly a question of affordability. There's no room for error when it comes to determining a patient's medical bill. Helping patients understand and plan for medical bills starts with calculating patient responsibility quickly and accurately. Incorrect charges, unexpected costs and confusing payment processes create poor financial experiences for patients. According to research by Experian Health and PYMNTS, patients are increasingly worried about their healthcare costs. 46% of those surveyed had canceled care after receiving a high-cost estimate, while 60% of those with out-of-pocket expenses said inaccurate estimates or an unexpected bill would prompt them to consider switching providers. As the stakes get higher, providers must reexamine how to calculate patient responsibility in medical billing so all parties are clear about who will pay for what. Providing that clarity will improve the patient experience, streamline patient collections and protect the organization from bad debt. What is patient responsibility? Responsibility for paying medical bills is apportioned between the patient who receives care, their insurance provider (if they have one), and government payers like Medicare and Medicaid (if the patient is eligible). “Patient responsibility” refers to the portion of the bill that should be paid by the patient themselves. Getting these calculations right is critical to the provider's revenue cycle. Determining patient responsibility starts during patient registration. Here, providers have their first opportunity to check that insurance details are up to date and ensure that the patient has not overlooked any active coverage. If the patient does not have coverage, they'll be liable for the whole bill (or will have to find charity assistance). If they do have insurance, the provider will liaise with their payer to check that the proposed care is covered under the patient's plan and establish any prior authorization requirements. Then, the provider can estimate how much of the cost of care should be reimbursed by the payer, and how much will fall to the patient. The amount paid by patients includes the following categories: Co-payment – this is a fixed, flat fee the patient pays toward their medical care at the time of service. If providers do not have accurate co-pay information available at the time of the visit, they may need to bill or refund the difference later. Not all health plans include co-payments, and those that do often specify exceptions. Deductible – this the total amount the patient must pay toward medical care each year before the payer contributes. For example, if a patient has a $1000 deductible, they must pay the first $1000 of medical bills that year, and any eligible costs on top of that will be covered by their payer or shared between the patient and payer. High-deductible health plans are attractive to patients who don't think they're likely to need care, as these plans often come with lower monthly premiums. However, if the patient does need care, they'll be left footing a greater portion of the bill. Coinsurance – this is the patient's share of remaining medical costs after paying their deductible. Out-of-pocket maximum – some health plans set an annual limit to the amount a patient needs to pay toward care, including co-payments, deductibles and coinsurance. Once that limit is reached, the payer will cover the remaining eligible expenses for the remainder of the period. Clearly, this is a complicated formula. To bill correctly, providers need to know whether the proposed treatment is covered by the patient's plan, how much the payer has agreed to pay for specific services, and whether individual service providers involved in the patient's care are in-network or not. Claims will only be reimbursed if all necessary coding and payer policy requirements have been met. Revenue cycle management tools to calculate patient responsibility Traditionally, providers have relied on teams of hard-working coders and billers to manually compile and review each claim. But with so many moving parts – not to mention frequent payer policy changes and staffing shortages – manual processes are no longer viable. When determining how to calculate patient responsibility in medical billing, providers should turn to automation and digital tools. This can help them augment their staff's capacity to calculate patient responsibility more efficiently and accurately and optimize patient collections. Here are a few examples of how they might do that: Automate insurance eligibility verification – Without understanding exactly what the patient's active coverage includes, providers will remain one step behind in the medical billing and claims management process. Payers are already using automation and artificial intelligence to fulfil their side of the equation, and providers cannot risk being left behind. Automating the verification process allows providers to capture up-to-date eligibility and benefits data, including the patient's co-pay and deductible amounts, to calculate the patient's responsibility pre-services. Find missing and forgotten coverage – As more patients switch health plans, more payers join the Affordable Care Act marketplace, and employer-based insurance changes, it's increasingly likely that the patient may not be 100% sure of their active coverage. With Coverage Discovery, providers can run quick, automated and repeated checks to see if any active coverage has been overlooked. This could drastically reduce the patient's responsibility, leaving them with a more affordable bill. Automate prior authorization – Many health plans require specific services to be authorized by the payer before being administered. Providers must check these requirements pre-service, or face a denied claim which could affect the patient's bill. Obtaining authorization from health plans before administering services can be slow and expensive, and often delays care. The Council for Affordable Quality Healthcare (CAQH) states that automating prior authorizations could save the medical industry $449 million per year (or 11 minutes per transaction). Automated prior authorization software gives providers real-time insights into payer requirements, so they can speed up reimbursement and give patients clarity over what they'll owe. Why use a patient cost estimator? With the necessary insurance information at their digital fingertips, providers can then use a patient responsibility pricer to calculate the patient's co-pays, deductibles and other out-of-pocket expenses. For example, Patient Payment Estimates is a web-based price transparency tool that generates personalized estimates for patients before and at the point of service. Patients get a comprehensive breakdown of what they'll owe, so they can plan for upcoming bills or even pay upfront. Patient liability estimator tools give patients more financial clarity, saving staff time and encouraging prompter payments. They're also an important compliance tool, and are specifically recommended in CMS advice on compliance with the Hospital Price Transparency Final Rule. Accelerate and streamline patient collections Early financial clarity encourages patients to pay sooner. This means it's more likely that those bills are paid in full, instead of lingering on the aged receivables list. In addition to upfront estimates, providers should make the payment process itself as easy as possible. This might include directing patients to payment plans or charity assistance, and connecting patients to convenient payment tools at any point in their healthcare journey. Inevitably, there will be some patients who simply cannot pay their bills. Collections Optimization Manager shows staff which accounts, so they don't waste time chasing the wrong accounts. By scoring and segmenting patient accounts based on the likelihood of payment, and adjusting as the patient's situation changes, Collections Optimization Manager helps providers manage resources more efficiently, while supporting a more compassionate patient financial experience. It also enables more effective use of collections agencies to minimize the cost to collect, and incorporates reporting and benchmarking tools to identify improvement opportunities. Find out how Experian Health's revenue cycle management tools can help providers calculate patient responsibility in medical billing, for a more compassionate patient experience and streamlined collections process.

What's weighing on providers' minds as we head into 2024? According to a 2023 Medical Group Management Association (MGMA) survey, an overwhelming percentage of providers are wondering how to speed up prior authorizations. The answer: automation and electronic prior authorizations. The 2023 MGMA Annual Regulatory Burden Report surveyed executives representing more than 350 group practices about the impact of federal policies and regulations. The MGMA is the nation's largest association focused on the business of medical practice management. Respondents cited a growing volume of pre-authorizations as a key challenge, along with complex coding requirements, lengthy response times, and delays in treatment. Survey results showed that prior authorizations are a pervasive issue: 89% of respondents called pre-authorizations either “very” or “extremely” burdensome. 90% said the regulatory burden has grown in the past 12 months. 92% had hired additional staff to deal with prior authorizations. 97% said patients had experienced delays or denials due to pre-authorization requirements. 97% said a reduced regulatory burden would allow resources to be reallocated toward patient care. Neeraj Joshi, Director of Product Management at Experian Health, sees the issue as complex but solvable: “Providers have to get ahead of the constant changes in regulations and payer rules, while also overcoming the operational limitations inherent in manual processes and the industry's ongoing staffing shortages,” he says. Joshi shared his perspective on the state of pre-authorizations going into 2024—and what may be ahead as providers consider automation and new technologies surrounding electronic prior authorizations. Here's where he sees the industry heading in the year to come. Q1: What feedback have you received from providers about the challenges they face, and how is this feedback shaping the development of Experian Health's solutions? “The feedback from providers is clear: They highlight the challenges of managing an increasing volume of pre-authorizations, the complexity of payer rules, and the burdens of manual data entry,” says Joshi. “This feedback has been crucial in shaping Experian Health's solutions, leading to the development of tools that automate the pre-authorization process and keep providers up-to-date with payer rules.” Technology plays a key role in helping providers take on these challenges. Case in point: Experian Health's online authorizations solution includes access to a complete payer database that stores and dynamically updates payer prior authorization requirements. Experian Health's pre-authorization Knowledgebase works together with Authorizations software to reduce the manual workload. Automated inquiries work behind the scenes without intervention to maintain a high level of accuracy that improves efficiency, drives revenue, and protects profits. “Features like the Knowledgebase and tools such as Medical Necessity, which automatically checks patient orders against payer rules, and Claims Scrubber, an automated solution that reviews and edits claims pre-submission, reduce the time and effort required to manage pre-authorizations and minimize the risk of errors,” says Joshi. “These tools address providers' specific challenges around maintaining operational efficiency and optimizing the revenue cycle as they navigate a complicated pre-authorization landscape.” Q2: Why are providers increasingly concerned about pre-authorizations now? “A number of factors are contributing,” says Joshi. “Providers' concerns about pre-authorizations have intensified due to the pandemic's impact on healthcare operations, leading to rescheduled care and uncertainties around existing authorizations. Additionally, evolving and diverse payer rules, coupled with manual, labor-intensive processes, have exacerbated these challenges.” Each of these concerns is significant by itself. Together, they create an even greater challenge to operational efficiency. “Providers are grappling with the need to adapt to these changes, often with reduced staff,” says Joshi. “This has increased the administrative burden and complexity of managing pre-authorizations. State-specific regulations, such as New York's temporary suspension of prior authorizations, have added another layer of complexity, creating a landscape where providers must continuously adapt to both national and regional policy changes.” Q3: How do regulatory changes impact the pre-authorization landscape, and how is Experian Health adapting to these changes? “Regulatory changes, including state-specific mandates and evolving payer policies, significantly impact pre-authorizations by introducing new requirements and exceptions,” Joshi explains. As of late 2023, 40 states have enacted prior authorization regulations, with the possibility of additional and amended regulations constantly looming. Additionally, the 2024 Medicare Advantage and Part D Final Rule will change pre-authorization requirements nationwide for patients with Medicare Advantage plans. Payer rules shift constantly—both in response to regulation and independent of it—creating a massive operational challenge for providers. “These constant changes necessitate a dynamic response from healthcare providers,” says Joshi. Outdated manual processes simply aren't up to the task, least of all when staffing is limited. “Experian Health helps providers adapt by continuously updating its platforms and solutions to align with the latest regulations and payer policies. This includes integrating real-time updates and automating the process of keeping track of changing requirements, thus ensuring that providers using Experian Health's solutions are always working with the most current information.” Q4: What other ways can electronic prior authorization tools help providers address current pre-authorizations challenges? “Leveraging technology to streamline and automate the pre-authorization process is the core advantage,” Joshi says. Electronic prior authorization tools, powered by AI, represent a giant leap forward.  “Adopting solutions that reduce manual workloads, such as Experian Health's Knowledgebase, and dynamic work queues that help operational teams work the exceptions and discrepancies, rather than spending their time handling every authorization transaction, can make complex processes manageable. Emphasizing back-end automation and keeping abreast of the latest payer policies are key strategies to manage increasing patient volumes effectively. “Providers can also focus on implementing patient-facing digital tools to facilitate self-service,” Joshi continues. “A greater emphasis on self-service can reduce administrative burdens without sacrificing the patient experience.” Q5: How do you see the future of patient care being impacted by electronic prior authorizations and other advancements? “The future of patient care is poised to be significantly impacted by these advancements,” Joshi says. “Streamlined and automated pre-authorizations can lead to reduced wait times for patients and more timely access to necessary treatments.” Automating the pre-authorization process and introducing new technologies to deal with an ever-evolving, ever-expanding workflow may also help providers break a difficult cycle of overwork and understaffing. “As the administrative burden on healthcare providers decreases, more resources can be allocated to direct patient care,” Joshi maintains. “This shift will not only improve the efficiency of healthcare delivery but also enhance the overall patient experience, leading to better health outcomes and higher patient satisfaction.” Learn more about how Experian Health can help your organization improve operational efficiency and drive revenue with electronic prior authorizations.