National Health Care Fraud Takedown Results in Charges against 301 Individuals for Approximately $900 Million in False Billing

Product featured in this article: Coverage Discovery As of the end of March 2021, more than 53 million Americans have been fully vaccinated, allowing for cautious optimism as we prepare for the next phase of the COVID-19 journey. Unfortunately for pharmacists, the vaccination program has compounded many of the challenges of the last 12 months. Shots may be free to patients, but someone has to pay for them – and getting reimbursed is proving to be a major pain. Complicated billing processes, extra billing audits and mountains of extra paperwork, rejected claims and slow payments are not exclusive to pharmacies helping vaccinate America. With the coronavirus pandemic continuing to muddy the insurance landscape, getting hold of missing dollars is challenging. Healthcare reimbursements haven’t been straightforward for other providers either: widespread coverage loss and uncompensated care is putting extra strain on hospital revenue cycles. With the coronavirus pandemic continuing to muddy the insurance landscape, getting hold of missing dollars is challenging. Providers must find ways to quickly and accurately determine each patient’s coverage status to minimize bad debt. Navigating the complex world of post-COVID healthcare coverage What does the reimbursement landscape look like, one year on? After a long wait, elective procedures are back. But the surge in patient volumes means providers must be on their toes to keep track of coverage. The process for doing so must be streamlined and precise. Ramping up capacity to verify and check coverage without burdensome paperwork is a must. Patient intake is under pressure. More patients are coming through the doors as a result of elective services and vaccination programs (though not always to their usual facility). COVID-19 hasn’t gone away, and with pockets of infection spikes, safety remains a top priority. Capturing adequate insurance information in this context is no mean feat. Running automated coverage checks as soon as the patient arrives will minimize face-to-face contact during admissions and avoid delays. Patient access and collections staff are overburdened. Manual checks are difficult when staff are operating remotely or in a socially distanced environment, and patient information might be incomplete. Automated self-pay scrubbing can help handle the volume. A tool with built-in reporting can also offer insights on workflow and productivity, to help spot opportunities for quicker claims processing. New digital healthcare technologies aren’t always covered by insurers. Telehealth, a life raft during COVID-19, tends to be covered less often by private insurers, compared to Medicare and Medicaid. Coverage checks must factor this in to avoid errors and wasted time. Providers should opt for tools that sweep for payer updates to telehealth coverage to avoid unnecessary delays or denials. Employment levels may be inching upwards again, but tracking coverage remains a challenge as patients start new jobs with new health plans. In addition, checking for Medicare coverage in the midst of changing codes and protocols is time consuming and confusing. A third-party resource such as Coverage Discovery can look for all coverage options and make sure the right bill goes to the right payer. Find missing dollars with Coverage Discovery Hospitals, pharmacists and other healthcare providers can’t afford to continue losing money at a time when every dollar is needed to prepare for “after COVID-19.” Experian Health’s Coverage Discovery is a proven system for tracking down missing coverage quickly and easily, to avoid unnecessary revenue loss. Using billions of data assets and intelligent confidence scoring, it combs through multiple government and commercial payer accounts to maximize actionable coverage. Staff can trust the outputs and focus their attention where it’s really needed. By making coverage identification more efficient and accurate, it’s a shot in the arm for providers in need of faster reimbursements. Contact us to see how Coverage Discovery can be easily integrated into your revenue cycle, so you can maximize reimbursements over the coming weeks and months.

Published: April 13, 2021 by Experian Health

A healthcare network with streamlined data management provides an environment where duplicate or inaccurate information is detected and corrected.

Published: January 26, 2021 by Experian Health

Finding previously unidentified insurance coverage can feel a little like a game of hide and seek. Patients may not always be aware of their insurance or eligibility for Medicare and Medicaid, and, in an effort to both improve the patient financial experience and simultaneously improve collections, providers are often tasked with finding this information on the spot. Historically, providers have used demographic information like Social Security Numbers (SSN) as a means to verify patient identities and locate this information, but that tactic is increasingly unreliable as it is possible for more than one person to use the same SSN and SSNs are a lucrative route to stealing someone’s identity. With this in mind, many health plans are no longer using SSNs as an identifying number for insurance coverage. In fact, the Centers for Medicare & Medicaid Services recently removed SSN-based Health Insurance Claim Numbers (HICNs) from Medicare cards and are now using Medicare Beneficiary Identifiers (MBIs) for Medicare transactions like billing, eligibility status, and claim status. The latest health plans to remove this piece of demographic information is Health Net Medi-Cal and Health Net National. Effective September 25, 2020, the search options for eligibility for this plan have changed. Providers will ONLY be able to find and verify coverage with a subscriber ID. \"Providers are often tasked with finding this information on the spot.\" While Health Net Medi-Cal and Health Net National are the latest health plans to do away with demographic searches, it’s certainly not a surprising trend and more will likely follow suit. Bridging the gap with historical data Uncovering previously unidentified coverage is critical for providers as it helps to eliminate costly self-pay situations, bad debt write-offs and unwarranted charity designations. And, without the proper insurance information, patients also risk delayed access to care and other financial hardships. With demographic searches on the decline, providers will need a more efficient and reliable way to search for coverage. As a data-driven company with a historical repository of claims data, Experian Health is uniquely positioned to help providers search for coverage. Combining search best practices, multiple proprietary databases and historical information, Experian Health’s Coverage Discovery locates patients\' billable commercial insurances that were unknown or forgotten, and combs through Medicare and Medicaid coverage. This flags accounts that may have been destined as a write-off or charity and maximizes reimbursement revenue by identifying primary, secondary and tertiary coverage. Not only do fewer accounts go to bad-debt collections, but providers can automate the self-pay scrubbing process. A tool like Coverage Discovery is even more beneficial for providers during COVID-19, where limitations of face-to-face contact make it more difficult to complete the usual coverage checks. Coverage Discovery empowers providers to facilitate coverage checks remotely, avoiding delayed reimbursements during a time when revenue streams are already feeling pressure. \"As a data-driven company with a historical repository of data, Experian Health is uniquely positioned to help providers search for coverage.\" Want to learn more? Contact us to see how Coverage Discovery can help find previously unidentified coverage and reduce bad debt.

Published: September 28, 2020 by Experian Health