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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.

As Spotify and Amazon can attest, digital technology plus personalization is a winning formula. Consumers want anytime-anywhere access to the services and products they enjoy, without having to sift through irrelevant information. They want tailored recommendations that will make their life easier. More than eight in ten consumers say they’re more likely to choose businesses that treat them like a person instead of just a number. The pay-off for business—and health plans—is huge: by paving the way for better services, better relationships and a better consumer experience, personalization boosts profits, too. There’s one challenge: delivering personalization requires data. Health plans that want to offer a member-centric experience need the right insights to build a complete picture of what individual members need and want. Yet many health plans are forced to work from stale or incomplete data, notably when CMS hands over a new list of members or a new employer signs on to the plan. A system like that makes it nearly impossible to provide meaningful personalization, and consequently, the member experience suffers. With originally sourced data and consumer insights, health plans can fill in the missing links in member profiles and maximize opportunities to improve the consumer experience. Here, we look at how three specific data-driven strategies could help your health plan attract and retain satisfied members and demonstrate digital excellence by using personalization to drive improvements in communications and care. Personalize member communications for maximum engagement By looking beyond simple demographic data and clinical information, health plans can discover what really matters to members. Consumer data provides detailed insights about the kind of content that will resonate most with the member’s lifestyle, interests and health circumstances. Health plans can tailor their marketing messages accordingly, by highlighting articles about the treatment of relevant medical conditions or sending reminders ahead of annual check-ups.Health plans can also discover when and how to communicate with members so they’re most likely to respond. When member profiles reveal who prefers an email or a text and when, health plans can elicit higher levels of engagement, improve the consumer experience and see better results from targeted outreach campaigns. Make improvement decisions based on the most relevant data Consumer insights can also be used to develop improvement plans that zero in on exactly what members need for the best possible health outcomes. Combining insights on patient behavior patterns with an understanding of the challenges facing individual members means health plans can segment members, so the right support goes to the right place.For example, efforts to drive up medication adherence are going to be far more successful if based off accurate and current member profiles. Specific members can be sent automated, personalized reminders to fill out prescriptions in good time before they run out. Compare that to a “spray and pray” awareness campaign using generic messages that are likely to be ignored. Data-led improvement strategies are operationally efficient and create a better experience for members. Help members overcome social barriers to health Finally, when member profiles include a snapshot of how social and economic factors influence their ability to access healthcare, health plans can take action to offer support. Closing the gaps in care that arise when a patient fails to turn up to their appointment or ends up being readmitted to hospital, can often involve quite simple solutions. If data suggests the member has small children, but there’s no other adult in the household, it makes sense to cross-promote childcare services. Similarly, if the member isn’t known to own a car, a health plan could offer information on free transportation.Understanding these social determinants of health can help health plans offer proactive support so members enjoy better health outcomes in the long run. Experian Health’s rich datasets give health plans access to member-level insights on more than 330 million consumers, with data analysis and automation tools to help make business decisions based on the most relevant, current data. Contact us to find out how we can help provide the personalized experience members are looking for.

    Many thought the end of COVID-19 was in sight with the availability of a vaccine, and while that is somewhat true, an entirely new set of issues has arrived: how to properly administer and manage the vaccine. Now that a COVID-19 vaccine is approved and underway, providers need to execute a medical billing and coding strategy to sustain vaccination efforts. We interviewed J. Scott Milne, senior director of product management at Experian Health, about what’s changed and what providers can do to prepare. How can providers ensure that vaccine administration codes are billed correctly? The ICD-10 and CPT codes for the COVID-19 vaccine haven’t existed until now, which means providers have a new set of codes to learn and unfortunately, those codes seem to change or update almost daily. As more vaccines are introduced, more codes are also introduced, and not just for the vaccine as a whole, but for each specific dose of the vaccine. For example, dose one of the Pfizer vaccine will have a code that differs entirely from dose two of the Moderna vaccine. Keeping up with these changes isn’t only difficult for provider staff, who are likely already stretched thin, but they certainly don’t want to run the risk of submitting a claim with incorrect information. The errors are what result in denials or undercharges. A solution like Claim Scrubber ensures code sets are current on a daily basis – a necessity for times like these – but applies an extensive set of general and payer-specific edits before preparing the claim for processing. That means claims for vaccine administration are error-free before submission to the payer or clearinghouse. Providers can eliminate undercharges, boost first-time pass through rates and do away with costly, time-consuming rework. But proper coding is only the first piece of the billing puzzle. The second piece is to verify the accuracy of payment received from third-party payers. How can providers ensure that third party payers will reimburse at the contracted rates? Providers can certainly get reimbursed for administering the vaccine, but there are a lot of moving parts to keep up with. For example, both Medicaid and Medicare will reimburse providers for administering COVID-19 vaccines, but the percentage of what is covered will differ by carrier and the reimbursement rates can vary both by state and type of arrangement. Reimbursement rates will also vary amongst private payers. Then there is the variation in reimbursement based on vaccine type and dosage — vaccines that require a single dose may be reimbursed at a rate different than those that require two doses. Even without the vaccine rollout underway it can be a headache for hospitals and health systems to manage multiple payer contracts and reimbursement methodologies. A solution like Contract Manager will pinpoint variance in reimbursement quickly and easily, accurately pricing claims and comparing actual allowed amounts to expected amounts. It is a tool built to adapt to changes within the industry, so providers can capitalize on emerging reimbursement schemes and changes in payer payment policies. It can also help identify sources and patterns of errors so recurring issues can be promptly resolved. The end result: the provider organization can the payer revenue that is due for vaccine administration. Interested in learning more about how providers can optimize vaccine-related reimbursements?   Other blog posts in this series: Segmenting your patient population for the COVID-19 vaccine Engaging patient segments with convenient, secure scheduling solutions Authenticating portal access with automation Optimizing reimbursements by capturing missing coverage