Eligibility Checking Part 2: Taking a Proactive Approach

In Part 1 of our post on patient eligibility verification, we examined some of the ways to check eligibility. This post details how practices can take a proactive approach to reduce denials due to eligibility issues.More than 20 percent of claim denials from private insurers are the result of eligibility issues, according to the American Medical Association. To reduce these types of denials, practices can employ two proactive approaches:1. The Basics - Many eligibility issues that result in claim denials are the result of simple administrative mistakes. Practices must have comprehensive processes in place to capture the necessary patient information, store it, and organize it for easy retrieval. This includes:o Obtaining the patient's full name directly from the card (photocopying/scanning is recommended)
o Patient address and phone number
o Obtain the name and identification numbers of other insurance (e.g., Medicare or other type of insurance plan involved). Again, photocopying/scanning of all health insurance cards is recommended.
o Patient's date of birth2. Looking Deeper - The increase in high deductible plans is making patients financially responsible for a larger percentage of a practice's revenue. Therefore, practices need to know their financial risks in advance and counsel patients on their financial obligations to improve collections. To accomplish this, practices need to look beyond whether or not the patient is eligible, and determine the extent of the patient's benefits. Practices will need to gather additional information from payers during the eligibility verification process, such as:


o The patient's deductible amount and remaining deductible balance
o Non-covered services, as defined under the patient's policy
o Maximum cap on certain treatments
o Coordination of benefitsPractices that take a proactive approach to eligibility verification can reduce claim denials, improve collections, and reduce financial risks. Practices that do not have the resources to accomplish these tasks in house may want to consider outsourcing specific tasks to an experienced firm.Specifically, there are certain patient eligibility checking scenarios where automation cannot provide the answers that are needed. Despite advancements in automation, there is still a need for live representative calls to payer organizations.For example, many practices use electronic data interchange (EDI) and clearinghouses with their EHR and PM solutions to determine if a patient is eligible for services on a specific day. However, these solutions are typically unable to provide practices with information about:• Procedure-level benefit analysis
• Prior authorizations
• Covered and non-covered conditions for certain procedures
• Detailed patient benefits, such as maximum caps on certain treatments and coordination of benefit informationImplementing these proactive eligibility approaches is important, whether practices handle them in house or outsource them, since denials resulting from eligibility issues directly impact cash flow and a practice's financial health.