The healthcare landscape has changed, and one of the biggest changes is the growing financial responsibility of patients with high deductibles that require them to pay physician practices for services. This is an area where practices are struggling to collect the revenue they are entitled. In fact, practices are generating up to 30 to 40 percent of their revenue from patients who have high-deductible insurance coverage. Failing to check patient eligibility and deductibles can increase denials, negatively impact cash flow and profitability. One solution is to improve eligibility checking using the following best practices: -Check patient eligibility 48 to 72 hours in advance of scheduled visit using one of these three methods: 1. Business-to-business (B2B) verification, which enables practices to electronically check patient eligibility using electronic data interchange (EDI) via their electronic health record (EHR) and practice management solutions. 2. Look up patient eligibility on payer websites. 3. Call payers to determine eligibility for more complex scenarios, such as coverage of particular procedures and services, determining calendar year maximum coverage, or if services are covered if they take place in an office or diagnostic center. Clearinghouses do not provide these details, so calling the payer is necessary for these scenarios. -Determine patient financial responsibilities – high deductibles, out-of-pocket limits, then counsel patients about their financial responsibilities before service delivery, educating them on how much they’ll need to pay and when. -Determine co-pays and collect before service delivery. Yet, even when doing this, there are still potential pitfalls, such as changes in eligibility due to employee termination of patient or primary insured, unpaid premiums, and nuances in dependent coverage. If all of this sounds like a lot of work, it’s because it is. This isn’t to say that practice managers/administrators are unable to do their jobs. It's just that sometimes they need some help and better tools. However, not performing these tasks can increase denials, as well as impact cash flow and profitability. In our next post we will examine ways to overcome these challenges.

1. HEALTHCARE LANDSCAPE...
This is an area where practices are struggling to collect the revenue they are
entitled to.
The Healthcare landscape has changed, and one of
the biggest changes is the growing financial
responsibility of patients with high deductibles that
require them to pay physician practices for services.
In fact, practices are generating up to 30 to 40 percent of their revenue from patients who have high-
deductible insurance coverage. Failing to check patient eligibility and deductibles can increase denials,
negatively impacting cash flow and profitability.
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2. SOLUTION TO
IMPROVE
ELIGIBILITY
CHECKING
One solution is to improve eligibility checking using the
following best practices:
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3. CHECK PATIENT ELIGIBILITY
Check patient eligibility 48 to 72 hours in advance of scheduled visits using one of these three methods:
Look up patient eligibility on payer websites.
Call payers to determine eligibility for more complex
scenarios, such as coverage of particular procedures and
services, determining calendar year maximum coverage, or
if services are covered if they take place in an office or
diagnostic center. Clearinghouses do not provide these
details, so calling the payer is necessary for these
scenarios.
Method 1
Business-to-business (B2B) verification, which
enables practices to electronically check patient
eligibility using electronic data interchange (EDI)
via their electronic health record (EHR) and
practice management solutions.
Method 1
Method 2
Method 3
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4. DETERMINE PATIENT FINANCIAL RESPONSIBILITIES
High deductibles, Out-of-pocket
limits, then counsel patients about
their financial responsibilities
before service delivery, educating
them on how much they’ll need to
pay and when.
Determine co-pays and collect
before service delivery.
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5. POTENTIAL PITFALLS
If all of this sounds like a lot of work, it’s because it is. This isn’t to say that practice
managers/administrators are unable to do their jobs. It's just that sometimes they need some
help and better tools. However, not performing these tasks can increase denials, as well as impact
cash flow and profitability.
Yet, even when doing this, there are still potential pitfalls, such as changes in eligibility due to employee
termination of patient or primary insured, unpaid premiums, and nuances in dependent coverage.
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6. TAKING PROACTIVE APPROACH
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:
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7. BASIC STEPS
Patient Name Address/Number Identification DOB
Obtaining the patient’s full name
directly from the card
(photocopying/scanning is
recommended)
Patient address and phone
number
Obtaining 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.
Patient’s date of birth
Many eligibility issues that result in claim denials are a 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. These include:
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8. DEEP APPROACH...
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:
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Patient’s deductible
amount and remaining
deductible balance
Non-covered services,
as defined under the
patient’s policy
Maximum cap on
certain treatments
Coordination of benefits

9. EFFECTIVE RESULTS
Outsourcing Tasks
Practices which 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.
Financial Health
Implementing 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.
99© Copyright 2014. Clinicspectrum, All Rights Reserved. 9

10. EFFECTIVE RESULTS
Outsourcing Tasks
Practices which 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.
Financial Health
Implementing 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.
99© Copyright 2014. Clinicspectrum, All Rights Reserved. 9