Whether or not a claim is paid or denied has a lot to do with what happens before a patient walks through the door. Incomplete or inaccurate information gathered on the front end can set the stage for a denial before a visit even gets started.
"It's critical to have as complete a patient record as possible before a patient presents," said Ben Colton, senior manager specializing in revenue cycle optimization at ECG Management Consultants in Seattle, Wash. "As the visit gets closer, you should use all lines of defense to verify information right up to the time of the visit."
Insurance verification has become increasingly important as more patients acquire high-deductible plans, said Lucy Zielinski, vice president of The Camden Group, a Los Angeles-based healthcare business advisory firm. As a result, it's vital to have staff members at the front desk who know how to interpret different policies and discuss coverage issues with patients.
"The skill set required of [someone at the front desk] today is very different from what was needed 10 or 20 years ago," said Zielinski. "In addition to customer service skills, you need to know the nuances of insurance policies and how to educate patients about their plans."
Automated insurance eligibility and verification tools help but cannot replace a knowledgeable staff and a solid pre-visit process, experts said. They offered the following advice for avoiding mistakes on the front end that can require expensive fixes down the road.
• Check and double check. Don't wait until a patient is in the office to verify insurance and collect demographic information, said Colton. Start the process during scheduling and follow up two days to three days before the visit. Review the details again at the time of the visit in case a patient's phone number, address, or other information has changed.
• Trace errors back to their source. Frequent communication between the front and back office goes a long way toward preventing repeated errors, said Colton. The best practice is to route any front-end issues that are causing denials back to the person responsible so he can modify his procedures.
• Offer price transparency. Along with eligibility verification, consider integrating a cost estimating tool into your practice management or EHR system. The tools, which are often available through insurers, provide an estimate of the cost of an upcoming service or procedure based on the patient's benefits and historical claims data. It's another way of educating the patient about her financial responsibility so there are fewer surprises when it comes time to bill the patient.
• Schedule appropriately. Ask questions about the details of the visit upfront to help you schedule the appropriate type and length for a visit, said Zielinski. For example, some insurers do not allow you to group preventative services, such as a routine physical, and procedures, such as a mole removal, into the same visit for billing purposes. It's also important to check on the date of a patient's last mammogram, physical, or other service that's typically covered annually to make sure it is covered at the time of service.
• Timing is critical. Mistakes made on the front end lead to delays filing claims, and that's money out of your pocket, said Zielinski. "You have to spend time researching the mistake, updating the claim, resubmitting it, and waiting for payment," she said. And all of that has to happen within the 90-day filing window required by many payers. "You run the risk of not getting paid at all," she said, "so that rework ends up being very expensive."