First Pst after migration to Cloud in Health care Blog

Because so many healthcare claim denials originate in the front end of the revenue cycle, providers should focus on improving insurance eligibility verification at the early stages of the patient journey. Verifying coverage earlier in the billing process with automated eligibility verification software increases the chance of submitting clean claims the first time and protecting future revenue. As coverage and benefits become more challenging for patients to navigate, prioritizing eligibility could also hold the key to better patient-provider relationships. Given the complexity of the healthcare billing system, patients have little tolerance for errors and delays. Many already worry about being able to cover their financial obligations, so denied claims are the last thing they want to see. Insurance verification reduces denials, gives patients greater clarity over their upcoming expenses and allows healthcare organizations to focus on providing the best possible care. This article looks at why improving insurance eligibility verification can help healthcare providers optimize cash flow and achieve higher levels of patient satisfaction and loyalty. What are the steps in the insurance eligibility verification process? Before filling out a claim, providers must be sure that the services they’re seeking reimbursement for are covered by the patient’s health insurance. They must also check that the patient’s details match those on their insurance plan. If a provider offers treatment or services and it later turns out that the patient’s coverage has expired or the patient is ineligible for those items, the claim will be rejected. To verify eligibility, providers must therefore be able to answer the following questions: Are the patient’s contact details current and correct? Does the patient’s insurance plan cover the planned treatment or services? Do any exclusions apply under the patient’s plan? Have all necessary pre-authorizations been obtained? Is the coverage active? What are the thresholds for deductibles, co-pays or coinsurance, and do any annual or lifetime limits apply? Confirming eligibility early on lays the groundwork for better claims management and minimizes the chance of errors. How does an effective eligibility verification system benefit patients and providers? Accurate and timely insurance verification clarifies to all parties how bills will be covered (or not) ahead of time. If a claim ends up being rejected, the patient will find themselves with responsibility for more of the bill, the provider will be left uncompensated for services rendered – or both. Clarifying coverage in advance avoids these scenarios. When providers can generate and communicate pre-service patient estimates with confidence, patients can plan for their bills and even make payments before or at the time of service. The financial benefits are clear, but patient satisfaction is also likely to increase: a study by Experian Health and PYMNTS found that patients who received pre-treatment estimates were more satisfied with their care than those who did not. Automated pre-service eligibility checks also improve communication between patients, providers and payers by reducing the manual workload on staff. Instead of spending time checking and fixing errors, staff can focus on helping patients with more complex cases. According to the CAQH, as much as $10 billion could be saved each year by switching to electronic eligibility and benefits verification. How does it help the claims process? In Experian Health’s report on the State of Claims 2022, the most common reasons given for claims being denied included: issues with prior authorizations, provider eligibility, patient information, changing payer policies and services not being covered. Automated eligibility verification helps solve each of these. With fewer errors in the pipeline, organizations can file claims faster and receive payments in a timelier manner. Eligibility Verification accesses up-to-date eligibility and benefits data from multiple sources, generating an instant read-out of a patient’s insurance status. More accurate information increases clean claims rates, accelerates reimbursement and allows providers to forecast future revenue levels more reliably. Staff can view responses in a clear and concise format and receive alerts when follow-ups or edits are required. This sets the tone for a more efficient claims process all around. Proactive and error-free claims management saves staff time that might otherwise be spent on reworking claims and engaging in lengthy disputes with payers. From the patient's perspective, earlier verification can fast-track registration because much of their information is checked before they even arrive for care. Waiting time is reduced because staff benefit from more streamlined workflows. As noted, finding missing coverage gives patients clarity over what they owe, so they’re more apt to pay bills on time. Automation can also be used to connect patients to the appropriate financial support. For example, with Patient Financial Clearance, providers can offer compassionate financial counseling and get patients on the right financial pathway. It improves the patient experience while reducing the risk of bad debt. What does a good insurance eligibility verification system look like? When it comes to choosing an insurance eligibility verification solution, the checklist should include the following features: Compatibility with existing systems and electronic health records – Eligibility Verification accelerates verification and registration by drawing together accurate patient data. And through eCare NEXT®, clients can manage multiple patient access functions through a single interface. Simple methods for updating or changing patient information – User-friendly interfaces allow staff to make changes from any device, as and when new information arises. Integration with patient portals means patients can spot errors themselves, too. And tools such as Registration QA can drive data accuracy by highlighting errors as soon as they occur, both pre-and at the point of service. Rapid results, with patient benefits information readily available when needed – Eligibility Verification confirms patient eligibility and calculates reimbursement estimates with precision. This incorporates CAQH COB Smart® data for enhanced coordination of benefits in relevant transactions. Ability to calculate patient estimates – A verification tool that integrates with automated patient payment estimates ensures patients understand their coverage, co-pays and deductibles before treatment proceeds so that they can plan for their final bills. Integration with pre-authorization tools – For some services, a payer may require the provider to seek authorization before going ahead. An insurance verification solution can flag up where prior authorization is needed to prompt action and prevent delays. Ability to source data from major health insurance carriers, including Medicare – Eligibility Verification connects with nearly 900 payers with advanced search functionality to match patients to current eligibility and benefits data. This can be used alongside an optional lookup service for Medicare beneficiaries to find and validate MBI numbers. Ongoing changes to the health insurance landscape mean that providers must pay close attention to the process of verifying coverage and benefits. Although insurance verification is a small step in patient access, the impact can be felt throughout the patient’s journey and the provider’s revenue cycle. By optimizing for earlier and more accurate insurance verification with workflow automation and advanced data analytics, providers can reduce the risk of denied claims, improve financial performance and protect patient-provider relationships. Find out more about how Experian Health can help healthcare providers streamline their claims process with front-end improvements to verify insurance eligibility, file error-free claims and get paid faster.

On April 1, 2023, millions of Medicaid recipients are set to lose coverage as the U.S. government’s COVID-19 public health emergency (PHE) expires. The Kaiser Family Foundation estimates that 5.3 to 14.2 million people will lose Medicaid coverage as the continuous enrollment provision of the PHE ends. Of this group, 6.8 million may be eligible to re-apply for Medicaid, but in the immediate term, it falls to patients and providers to sort through coverage questions, navigate charity and Medicaid eligibility, and keep bills out of collections. Mindy Pankoke, Senior Product Manager at Experian Health, shares her insights on how Patient Financial Clearance and other digital solutions can help providers and patients cut through the confusion to achieve the best healthcare and financial outcomes during this time. Q1: The public health emergency is ending on April 1, which means that many will lose Medicaid coverage. How will this impact providers and patients? “Patients who qualified for Medicaid under the Public Health Emergency requirements during COVID will be dropped from Medicaid on April 1, leaving them without coverage,” explains Pankoke. “Healthcare organizations have been trying to reach out proactively to pre-enroll some of these patients, but others may not know what their options are or may show up to receive care without realizing they no longer have coverage.” Patients will face a range of financial challenges. “Self-pay patients may defer treatment, which could keep them from receiving the care they need and may ultimately lead to more costly hospital visits,” Pankoke says. “Also, patients may be confused about what’s happened to their coverage and what their options might be going forward. If they end up being responsible for paying out of pocket for care, some may have to choose between paying their medical bills and paying for food or utilities.” Providers will see a surge in patients needing help after losing Medicaid coverage With millions of patients in flux, providers will need to dedicate time and attention to helping patients sort through their concerns, including: Confirming whether Medicaid coverage is still in force Verifying coverage with new insurance Determining eligibility to re-enroll in Medicaid Qualifying patients for full or partial charity care Explaining patient financial responsibility and working out payment plans Managing billing and collections with a higher volume of accounts in AR Optimizing outcomes so that patients get the best care possible and providers end up with the least amount of bad debt Time is a critical element. Lengthy processes and administrative delays are likely to increase patient stress levels. Meanwhile, many providers face industry-wide staffing shortages. Time-consuming manual processes, multiplied by a sudden surge of affected patients, could quickly become overwhelming for staff. “For providers, this could be a hard situation to navigate,” says Pankoke. “At the same time, it gives providers an opportunity to come through for patients in a moment of need. Being able to identify patients who need assistance and offering them help can be powerful.” Q2: That raises an important question: How can providers create a compassionate experience for patients? “I think awareness is one place to start: making sure your staff knows this change is coming and that they understand the impact,” Pankoke says. “Your staff are the ones who’ll be working with patients personally when they come in and find out they no longer have Medicaid coverage.” But compassion doesn’t end there. “Many providers already have charity programs in place to provide relief for patients who can’t afford care,” says Pankoke. “The challenge lies in identifying the patients who need that charity assistance and connecting them to the help that’s available, while also learning which patients may still qualify for Medicaid and need help to re-enroll. Patient Financial Clearance uses credit and non-credit data to identify patients who may still be eligible for Medicaid, as well as self-pay patients who may qualify for charity assistance.” Using data-driven digital tools to quickly and proactively size up patient financial needs and offer personalized help can make the patient experience more humane. “Making these steps easier is another piece of being compassionate.” Q3: Screening for charity can be complicated, especially when new regulations are introduced – how do providers streamline this process? “My best advice is to embrace your charity programs and use a partner like Experian Health to help you automate the financial assistance screening process,” says Pankoke. “Patient Financial Clearance removes the manual screening for the likelihood to qualify for your charity programs and Medicaid.  It can automate the document-gathering in a patient-friendly way, and speed up the process to extend charity assistance, or work to enroll those likely to qualify for Medicaid early on before patients go through a costly uncollectable experience.” Automating these processes doesn’t have to be onerous. “Clients can provide their charity policy  requirements to Experian Health and let our expert consultants help to create the most effective and efficient workflows for Medicaid and charity screening both  up-front and as back-end scrubs.” Pankoke also urges providers to consider patient self-screening options as well: “Providers should consider other options aside from paper applications.  We’ve seen clients shrink the application process from 60 days of paperwork down to 3.5 days by enabling patient self-screening options via text.  This creates a better experience for the patient and hospital staff.” Q4: What else can providers do to help patients manage the cost of care? Providers can focus their resources on improving the patient's financial journey—for all patients, not just those who are struggling with their Medicaid status. Pankoke’s suggestions: Reach patients on their preferred channels – “Providers can empower patients with less paper-heavy ways to apply for financial assistance. Text and online applications embedded on your website or patient portal put the power into the patient’s hands using the channels they prefer.” Providers can also offer patients the ability to make payments right from their mobile devices using Patient Financial Advisor, making it easier to pay outstanding bills anytime and anywhere. Use data to gain insight into patient finances and offer personalized options – “In addition to screening for possible charity and Medicaid eligibility, Experian data enables providers to offer realistic payment plan options that consider how much the patient is likely to afford, enabling patients to bite off what they can chew with higher likelihoods of making payments successfully.” Customize collections – Sending patients who are struggling to collections may not be cost-effective or compassionate. “Providers don’t want to hound people for payment if the patient is having trouble covering their basic expenses and could qualify for Medicaid or charity care,” says Pankoke. Using Collections Optimization Manager, providers can tailor collections processes to their own specific needs. “A partner who is agnostic to your in-house and early-out agencies can help you manage, monitor, and optimize agency performance for maximum revenue.” Providers who are concerned about upcoming shifts to Medicaid coverage may want to consider leveraging solutions like Patient Financial Clearance, Collections Optimization Manager and Patient Financial Advisor to help them meet this challenge—along with the many challenges of managing patient financial needs in a rapidly-changing world.

“The challenge we sought to overcome by leveraging AI Advantage at our organization was just gaining more insight into how denials originate and what actions we can take to prevent those from happening.” — Skylar Earley, Director of Patient Financial Services, Schneck Medical Center Challenge Starting as a 17-bed hospital more than 100 years ago, Schneck Medical Center now serves four counties in Indiana, with a staff of more than 1,000 employees, 125 volunteers and nearly 200 physicians. The organization’s vision is to deliver excellence, lead transformation and advance health, underpinned by a patient-first philosophy. For the Patient Financial Services team at Schneck Medical Center, reworking denied healthcare claims was often time-consuming and inefficient. Billers tended to prioritize high-value claims, without knowing the probability of reimbursement. They sought a denial management solution that would reduce the risk of denied claims and minimize their impact on the revenue cycle. Solution Schneck worked with Experian Health to test two new denial management solutions that use artificial intelligence (AI) to reduce the likelihood of denials and prioritize rework to maximize reimbursement. The first, AI Advantage™ – Predictive Denials, uses AI to predict claims that have a high chance of being denied, so they can be corrected before the claim is sent to the payer. If a claim review exceeds the suggested threshold for denial probability, an alert is triggered, and the flagged claim is automatically routed to the appropriate biller. The biller investigates the alert to understand what changes are needed. This might include checking insurance eligibility, reviewing coding errors or reviewing authorization status. Once the alert is resolved, the claim can be automatically resubmitted. The second solution, AI Advantage™ – Denial Triage, prioritizes denials based on the potential for reimbursement so staff can focus recovery efforts on the right claims. The triage process starts with identifying between 2 and 10 denial segmentation categories based on likelihood of reimbursement. Schneck chose to identify 5 categories to start. Individual remits are evaluated and automatically assigned to the appropriate category, so they can be routed to the correct specialist. The tools use historical claims data and a continuously learning AI model to detect patterns in payer decisions. Staff can customize denial probability thresholds and segmentation criteria to ensure claims are routed to the correct specialist. The solutions integrate seamlessly with Schneck’s existing claims management system, ClaimSource®, and other health information workflows. Outcome After just six months, AI Advantage helped Schneck reduce denials by an average of 4.6% each month. Corrections that would previously have taken 12 to 15 minutes to rework can now be processed in under 5 minutes. Staff report that the thresholds determined by AI Advantage – Predictive Denials are highly accurate, leading to better decision-making when reworking claims prior to submission. And with AI Advantage – Denials Triage, staff feel confident that they’re focusing their attention on the right segments, rather than wasting time on high-value claims that are unlikely to be reimbursed. Skylar Earley says, “Before, we had no insight into whether we were performing value-added work when we followed up and worked denials. Now we see those percentages.” Learn more about how AI Advantage generates insights to help healthcare organizations reduce time spent working denials and maximize reimbursement.