Care Management

Tracking down missing health coverage has always been challenging for providers, but proposed changes to the Affordable Care Act and Medicaid could make it even tougher. If the reforms take effect, as many as 13.7 million Americans could lose health insurance over the next decade. With more patients cycling in and out of coverage, many will turn up for care without knowing their coverage status, leaving them at risk for bills they can't afford and exposing providers to denials and revenue loss. Insurance verification has traditionally relied on Social Security Numbers (SSN). As the industry moves away from this approach, providers need faster, more reliable ways to confirm health insurance without SSNs. Health insurance without an SSN? The challenge of missing SSNs in patient records For decades, the SSN was a go-to data point for verifying insurance coverage. In the absence of a national patient identifier, it served as a consistent way to match individuals to their insurance records across health systems and payers. However, many patients do not have SSNs, and concerns about data privacy, duplication and identity theft led providers and payers to phase out SSNs. Although SSNs may still be collected during enrollment for administrative use, industry best practice now discourages using SSNs unless absolutely necessary. Recognizing the need for more secure and trustworthy identifiers, many payers have moved away from SSNs. For instance, in 2018, Medicare replaced SSN-based Health Insurance Claim Numbers with Medicare Beneficiary Identifiers (MBIs). These are now the primary means of checking a person's identity for Medicare transactions like billing, eligibility status and claim status. Commercial health plans have followed suit, relying more heavily on member IDs and internal identifiers for billing and eligibility and avoiding SSNs in patient records in line with privacy rules set out in the Health Insurance Portability and Accountability Act. As a result, SSNs are disappearing from patient records and payer databases. The question for providers is how to accurately verify insurance without SSN access. The impact of unidentified insurance on claims and reimbursement When active insurance coverage is overlooked, providers lose the opportunity to bill for care. Some patients will be incorrectly assigned self-pay status, triggering unnecessary billing cycles or charity write-offs. Others get care without providing their coverage information at the time of care, especially in fast-moving outpatient and emergency departments. Either way, the revenue is at risk in situations like these. Providers lose time and revenue. Teams are forced to reprocess claims, track down retroactive coverage, and appeal denials that could have been avoided. Missed coverage also takes a toll on patients, who now owe more than $220 billion in medical debt. And with cost concerns prompting four in ten patients to consider skipping care when they don't receive a price estimate, missing coverage is more than a paperwork problem – it's a clear threat to health and well-being. Case study: How UCHealth saved over $3.5 million by reducing accounts sent to collections with billable insurance. Strategies to identify health insurance without an SSN As the use of the SSN in medical billing declines, providers are looking for new and better tools to find insurance coverage. Digital technology and data integration make it possible to verify insurance without SSN use. Here are a few of the most effective strategies: 1. Using probabilistic matching and third-party data Advanced coverage discovery platforms now use probabilistic matching to connect patients to payers. These tools analyze data points like name, address, date of birth and phone number to identify likely matches. Instead of needing a patient's exact identifiers, they calculate match confidence based on data quality and historical payer data. 2. Leveraging health information exchanges (HIEs) Another option is to connect to regional or statewide HIEs to check insurance details shared across health systems, payers and public programs. This is especially valuable for transient or underserved populations who often move between providers and may not always carry updated insurance cards. 3. Patient self-service portals with identity validation At the front end, patient self-service tools offer opportunities to collect insurance information before a visit. Identity validation technology helps confirm the person's identity without requiring an SSN. Patients can scan an insurance card, update coverage details or answer verification questions within the portal. This reduces the workload for front desk staff and ensures better data before the patient arrives. Automated tools to streamline insurance discovery While patient access tools help patients confirm their coverage details, automated back-end solutions are essential for identifying insurance when information is incomplete or missing. Intelligent coverage discovery platforms can predict and verify active coverage without relying on SSNs, using demographic inputs like name, address and date of birth. These platforms run real-time or batch searches across multiple proprietary databases, combining search best practices, historical claims data and payer response patterns to flag likely matches. At the point of scheduling or registration, automated eligibility checks help identify billable coverage early, reducing errors, manual work and missed reimbursement opportunities. Experian Health's Coverage Discovery® exemplifies this approach, uncovering commercial, Medicare and Medicaid coverage that may have been unknown or forgotten. By identifying primary, secondary and tertiary coverage, it flags accounts that might otherwise be written off or sent to charity. Not only does this help maximize reimbursement revenue, but it also automates the self-pay scrubbing process and reduces the number of accounts sent to bad-debt collections. In 2023 alone, the platform identified billable coverage in more than 30% of self-pay accounts, resulting in over $25 million in found coverage. This level of automation is especially critical as policy changes continue to disrupt coverage stability. Proactive alerts can flag patients previously marked as self-pay but now linked to valid insurance, helping providers course-correct before claims go unpaid. Better patient matching, better outcomes As insurance coverage becomes more complex, providers need smarter and more efficient ways to verify it. Automated platforms like Coverage Discovery identify active insurance using minimal patient data, improving accuracy and reducing dependence on SSNs. When active coverage isn't found, Patient Financial Clearance helps fill the gap, screening for Medicaid eligibility or identifying patients who may qualify for charity care. Together, these tools give providers a more complete financial picture and ensure patients are connected to the coverage or support they need. The result is not just cleaner claims and faster payments, but better patient and provider outcomes. With more than a fifth of patients experiencing delays in healthcare because of issues verifying insurance information, improving coverage accuracy is a win for everyone. Find out more about how Coverage Discovery can help healthcare providers reduce bad debt by verifying patients' health insurance coverage without SSNs. Learn more Contact us

Flu season is rapidly approaching, which means healthcare providers must ramp up their preparedness efforts. What can they do to ensure they're ready to meet the seasonal surge in demand? Recent data from the southern hemisphere, often a forecast of what's to come in the US, suggests that this year's flu season will likely be similar to last year. The CDC warns that while “we cannot predict what will happen in the United States this upcoming season, we know that flu has the potential to cause significant illness, hospitalizations and deaths.” With hundreds of thousands of people hospitalized each year, providers must find ways to prepare for rising patient volumes and manage the risk of infection among patients and staff to keep services running smoothly. Making it as easy as possible for patients to book and attend vaccination appointments will be critical. Digital patient access will be the key to streamlining patient care. Using digital tools to prepare for flu season 2024-25 As services face increasing pressure, digital and automated tools can help healthcare providers prepare for flu season by easing staff burdens. More patients mean more appointments to schedule, more registration forms to fill out and more people in waiting rooms. Opening the digital front door helps manage high volumes by allowing patients to complete more access tasks online and prevent bottlenecks. Here are three strategies to implement to support staff and patients through a challenging season: 1. Manage infection risk with online self-scheduling An online patient scheduling platform has two clear benefits – it relieves pressure on staff during busy times and gives providers control over patient flow. Fewer calls need to be made by call center agents. No-shows are less likely because patients can book, reschedule and cancel appointments, and receive automated reminders, which makes the best use of physicians' time. Online scheduling also plays a part in infection control as providers can incorporate screening protocols to identify patients with symptoms of COVID-19 or flu, and manage their onward care pathway appropriately. Empowering consumers to take control of their healthcare with a patient scheduling system might encourage vaccine registrations, which could help reduce the burden on health services when staffing shortages remain stubbornly high. What's more, patients now expect the flexibility and convenience of scheduling appointments at a time and place that suits them. Experian Health's 2024 State of Patient Access survey found that six in ten patients want more digital tools to manage their healthcare. This indicates a growing demand for easy, simple and transparent processes. Watch the webinar: See how IU Health used self-scheduling to manage increasing patient volumes with less staff – and gain insights on using digital scheduling to scale operations beyond flu season. 2. Offer mobile registration to manage demand Should patient volumes increase, patient access staff will be under even more pressure than usual. Anything that can reduce the administrative burden will be a win. Experian Health's Registration Accelerator allows patients to complete intake forms and insurance checks through their mobile devices before stepping through the door. Their details can be pre-filled automatically, reducing the risk of error. This creates a quicker, more efficient patient registration experience that minimizes issues for staff to resolve. Mobile-enabled registration is also far more appealing for patients, who'd rather complete registration from the comfort of home than sit in a waiting room filling out lengthy forms. Plus, it reduces in-person interactions, thus minimizing exposure to infection among staff and patients. Given that 89% of patients say digital or paperless pre-registration is important to them, providers that offer online patient intake solutions will have a clear advantage in attracting potential new customers during times of high demand. 3. Reduce no-shows and increase engagement with automated patient outreach Providers must communicate proactively with patients to keep them in the loop as the situation evolves. With an open rate of 98%, text messages are a direct and convenient way to communicate quickly with patients. Automated patient outreach can increase vaccination rates by notifying patients about flu shot availability and offering a direct link to schedule an appointment. Automated reminders reduce no-show rates and help ensure no slot goes unused as patient volumes increase. Messages can also include tailored instructions for specific at-risk groups to emphasize the importance of timely vaccination and provide directions. This approach helps manage patient flow, increase patient satisfaction and ensure providers are prepared for the seasonal surge. Contact Experian Health today to learn how digital patient access solutions can help healthcare providers prepare for flu season in 2024. Learn more Contact us

Compared to other industries, healthcare tends to be more resilient to economic turbulence. But the weight of the pandemic, labor shortages, rising costs and increasingly complex reimbursement structures are squeezing hospital margins. A Kaufman Hall National Hospital Flash Report in July 2023 found that many hospitals underperformed, and the gap between high-performing hospitals and those struggling continues to widen. Providers must find new and effective ways to improve revenue cycle management, should any new uncertainties emerge. With pressure mounting to increase efficiency and reduce expenses, more providers are turning to automation and artificial intelligence (AI) to eliminate unnecessary manual work and optimize revenue cycle management processes. For example, Stanford Health Care leveraged automation to reduce their cost to collect. Banner Health improved patient collections with transparent price estimates. Schneck Medical Center zeroed in on claims management and incorporated AI to reduce denials. In the face of a cashflow crunch, healthcare providers increasingly turn to data-driven revenue cycle management (RCM) strategies that span the entire patient journey. This article lists six of the most effective income-generating digital RCM strategies that providers are using to maximize profits. Building blocks of a healthy revenue cycle At its core, revenue cycle management is about ensuring providers are fully reimbursed for the care they provide. The true ROI is much broader – efficient financial and administrative processes for patient billing, claims management and collections contribute to better care, satisfied patients, high-performing staff and good financial health. Realizing these benefits calls for revenue cycle processes built on three principles: Efficiency – streamlining processes to reduce resource utilization across the entire billing cycle Accuracy – ensuring all patient and claims data is correct and complete to avoid denials and delays Transparency – giving patients, providers and payers relevant and timely information, so they can act with confidence in each financial transaction. To achieve this, providers are moving away from slow, costly manual systems. Digital RCM tools are becoming non-negotiable. 6 data-driven strategies for effective revenue cycle management 1. Increase efficiency in patient access Revenue cycle management starts when the patient books their appointment and ends when the final bills are settled. Claim denials and delayed payments often arise from data errors and miscommunications in the early stages of the patient journey, which means patient scheduling and registration processes are critical to streamline RCM. With automated, data-driven patient access tools, providers can simplify tasks across the patient journey, so patients can move from one stage to the next with as little friction as possible. Fewer errors mean delays and disappointment are more easily avoided. Automated registration and online self-scheduling can also lead to savings through more efficient use of staff time and reducing the number of appointment no-shows. Experian Health clients find that online tools allow them to make relatively minor adjustments to their workflows, with a major impact on productivity. 2. Deliver accurate and timely patient billing Patients want the payment process to be as painless as possible. In multiple surveys, Experian Health has found that patients are worried about the cost of care, while 63% of providers believe patients frequently postpone care because of cost concerns. Clear, comprehensive estimates, billing and collections practices can make it easier for patients to navigate their financial journey. And with the end of continuous Medicaid enrollment, it's likely that more patients will find themselves unsure of their coverage situation, and in need of greater support to manage the financial process. For Stanford Health, the key to improving revenue cycle management centered around patient billing and collections. To achieve the dual goals of improving the patient experience and increasing collections, they used data-driven insights and automation to remove uncollectible accounts, prioritize accounts with a high propensity to pay, find missing coverage and reduce the manual workload. Collections Optimization Manager helped Stanford Health identify the best possible collections strategy, by scoring and segmenting patient accounts with the highest propensity to pay. Coverage Discovery® supplemented this strategy by checking for any unidentified primary, secondary or tertiary coverages that can potentially reduce self-pay amounts and avoidable charity designations. As a result, Stanford Health achieved a $4.1m increase in average monthly payments and efficiency gains of $109k per month. 3. Provide transparent price estimates Experian Health's State of Patient Access 2023 report suggests that fewer than three in ten patients know how much their care will cost in advance, while nine in ten consider it important. Delivering accurate pre-care estimates to help patients plan for bills could therefore be an easy win to improve the patient experience and recoup more revenue. Banner Health used Patient Estimates as part of a wider strategy to improve patient collections. This solution generates detailed estimates of the patient's financial responsibility along with recommendations for payment plans and financial assistance, if appropriate. Listen in as Becky Peters, Executive Director of Patient Access at Banner Health, talks about streamlining the patient registration process and improving patient access with pre-care estimates. 4. Effective claims management Perhaps the biggest opportunity to improve revenue cycle performance lies in claims and denial management, which accounts for a major proportion of wasted healthcare dollars. Summit Medical Group Oregon–BMC paired Enhanced Claim Status with Claim Scrubber to submit cleaner claims the first time and avoid lost revenue. These tools help providers submit accurate claims and monitor claim status to prevent denials and resolve issues quickly. For Summit Medical Group, this led to a 92% primary clean claims rate, and a reduction in accounts receivable days and volume by 15%. Experian Health also offers a new solution that leverages machine learning and artificial intelligence for predictive reimbursement. AI Advantage™ uses AI to predict and prevent claim denials based on historical claims data. In the first six months, this solution helped Schneck achieve a 4.6% average monthly decrease in denials and decreased time spent on denials by 4x. 5. Easy ways to pay (plus clear pricing and payment policies) How easy is it for patients to pay? This simple but important question points to another vital element of effective revenue cycle management. A compassionate and convenient patient payment experience that matches consumer experience in other industries can encourage earlier payments. Easy digital options are especially important for millennial and younger patients: research by Experian Health and PYMNTS found that 60% of younger patients are looking for digital services. Experian Health's patient-friendly payment tools are designed to help patients navigate their financial responsibilities with confidence and ease. For example, PaymentSafe® allows providers to securely collect payments anytime, anywhere, including mobile payments and patient portals. 6. Operational efficiency with automation, data and analytics RCM processes generate vast amounts of data, providing valuable insights into the organization's operational performance, revenue trends and areas for improvement. Being able to parse and translate this data into actionable insights is essential to determine the right strategies to pursue to optimize financial performance. But this in itself can be a major lift. Revenue Cycle Analytics is a web-based tool that breaks down data into actionable insights across billing, reimbursement and payer performance, presenting KPI data via comprehensive dashboards. Effective revenue cycle management strategies from start to end From labor shortages to rising costs, healthcare providers are finding creative ways to manage cash flow. While each healthcare organization’s needs and goals are different, understanding these six key strategies of successful revenue cycle management can help hospitals manage their revenue cycles more effectively and efficiently, while responding to new uncertainties. Find out more about how Experian Health helps healthcare organizations leverage automation and AI to streamline processes and boost revenue cycle performance.

The healthcare staffing crisis was one of the biggest challenges facing healthcare providers pre-pandemic, only to be exacerbated by the pressures of dealing with the COVID-19 crisis. Almost a fifth of healthcare workers resigned between February 2020 and September 2021. Unfortunately, the problem isn't in the rearview mirror yet – a new study from McKinsey reveals that worker shortages persist, with 31% of nurses declaring their intent to leave their jobs in the next year. These shortages put pressure on remaining staff, compromise hiring efforts and make high-quality services difficult to maintain. Without a thriving, vibrant workforce, how can healthcare providers meet the needs of their patients? Can automation help address the healthcare staffing crisis? Stubborn staff turnover levels aren't unique to healthcare, but addressing them is even more critical, given the detrimental effect on patients. As the staffing crisis shows no signs of letting up, providers should consider how technologies that leverage automation and AI can help. Tom Cox, President at Experian Health, says, “Automation has transformed many aspects of healthcare, from driving down appeals and denials to improving the digital front door. We're now seeing AI starting to make waves, too. These technologies are the future and are changing healthcare for the better.” Opening healthcare's digital front door is a good place to start. By eliminating repetitive and time-consuming tasks like data entry, manual patient registration and prior authorizations, staff will be freed up to focus on what matters most: delivering high-quality patient care. Here, we look at three areas where automation can simultaneously alleviate the burden of staff shortages and create a better patient experience. Use case 1: automate patient access to manage the growing demand for services Manual and repetitive processes eat up valuable time and create greater workloads that contribute to staff burnout. This is especially true in patient access, which is a typically admin-heavy process. Allowing patients to complete more of their registration and scheduling tasks themselves can reduce the workload in understaffed teams. Many patients prefer not to book appointments through call centers, and high call volumes are a major pressure point for staff. Similarly, manual patient registration is labor-intensive and error-prone, eating up staff time and creating bottlenecks for patients. Automated registration and self-scheduling solutions help patients access care without waiting in phone queues. Patients can book, cancel and reschedule appointments through their mobile devices. On the back end, data can be leveraged to predict and manage demand, while digitized scheduling means agents can spend less time checking referrals against scheduling rules. Automated prior authorizations mean staff no longer need to spend hours poring over payer policies and checking individual payer websites to check for changes – the software updates automatically in real-time. Simplifying these processes with automation not only minimizes operational strain but also reduces friction for patients who want to see the right specialist in the least amount of time. Use case 2: automate personalized patient outreach to reduce call volumes Another way to reduce the administrative burden is with automated patient outreach. Reducing no-shows is an important strategy to promote better health outcomes and boost financial performance. Instead of burying staff with a list of patients to follow up with, providers should utilize automated patient reminders. Automated patient outreach solutions allow providers to segment patients according to their individual needs and preferences, so patients get relevant information through the most appropriate channel. This allows patients to proactively and conveniently manage their own healthcare journey. Automated messages can also be sent to remind patients of outstanding bills and link them to payment options. This means patient collections teams can spend less time on calls and focus instead on meaningful conversations with patients who need extra guidance or support. Use case 3: automate patient collections for faster payments and a better patient experience With fewer staff, patient collections teams must figure out which accounts to prioritize, while navigating increasingly complex payer policies. Advanced data analytics and automation can be used to make these processes more efficient. Similarly, automated patient collections software can screen and segment patient accounts to allow staff to quickly prioritize those with the highest probability of being paid. Collections Optimization Manager offers convenience and clarity to staff with an easy-to-use interface, while targeted collections strategies facilitate conversations with patients based on accurate information and fewer calls and emails. Speed and accessibility create a better experience all around for both patients and staff. Using automated solutions to reduce the pressure of the healthcare staffing crisis Cox says, “Over the last few years, Experian Health has focused on helping providers and payers solve the immediate challenges associated with a remote workforce and staffing constraints while scaling services in response to surging demand. Integrating automation with self-service tools is just the beginning. Our vision is to continue driving innovative and automated solutions that will improve care outcomes and transform our clients' healthcare operations.” These are just a few examples of how automation can create new opportunities for healthcare providers. Digital processes that were once considered merely “nice to have” are now critical components to alleviate the healthcare staffing crisis and deliver positive patient experiences. Contact us to find out more about how Experian Health can help your organization use automation to alleviate the healthcare staffing crisis.

The consequences of failing to properly verify patient insurance eligibility can wreak havoc on the healthcare revenue cycle. Incorrect patient information, expired policies and missing pre-authorizations can all contribute to denied claims and delayed payments. But with patients bearing a greater responsibility for the cost of care and switching health plans more often, verifying eligibility has become more complex. As patient volumes grow, manual verification processes are increasingly vulnerable to errors. Health insurance eligibility verification software helps providers solve this problem. Few things are more frustrating for healthcare leaders than costly denials that could have been avoided. In a survey by Experian Health, one in three healthcare executives said claims are denied 10%–15% of the time, costing billions of dollars in lost revenue. An automated solution that eliminates errors and reduces denials could pay big dividends across the revenue cycle. This article breaks down the key revenue-boosting benefits of health insurance eligibility verification software: What is eligibility verification? Eligibility verification is the process of checking that a patient’s insurance information is correct and that the services they are seeking are covered under their existing plan. Providers are responsible for verifying the patient’s enrollment status before offering care. Once active enrollment is confirmed, providers will also need to verify the benefits included in the patient’s plan, to be sure that the cost of specific services and items will be covered. This involves the following steps: Checking the patient’s identity and contact information and ensuring that the details on their insurance card match their electronic health record Determining whether the patient’s insurance plan covers the services they expect to receive and that no exclusions apply Confirming that the patient is eligible for proposed services or treatment, for example by ensuring that any pre-authorization or referral requirements have been fulfilled Double-checking that the patient’s coverage is active and that they haven’t exceeded any annual or lifetime limits. "If providers don’t have a full picture of the patient’s payable benefits, deductibles, co-pay thresholds out-of-pocket maximums, and other policy details, they run the risk of non-reimbursement," says Kate Ankumah, Product Manager at Experian Health. "For that reason, these checks should be carried out before a patient’s appointment or procedure, to prevent awkward billing issues and delayed payments. This gives providers peace of mind that they’ll be reimbursed for the services they provide and accelerates patient registration." Carrying out these checks manually can be a time-consuming and laborious process. Staff must check individual payer websites and portals or phone insurance companies to get hold of the necessary information, all while speaking to the patient. Batch processing by medical claims clearinghouses can be a more efficient way of managing eligibility checks, though individual accounts may take longer to clear. What are the benefits of using health insurance eligibility verification software? Given the scale and impact of eligibility checks, many providers turn to insurance verification software to streamline the process and achieve higher levels of accuracy. This offers several benefits to providers and patients: Reduced risk of bad debt - In the world of healthcare claims, errors are expensive. Eligibility verification software can pull from multiple data sources at the click of a button, to give an instant and accurate read-out of a patient’s current insurance details and identity information. Reliable data helps prevent billing errors, thus reducing the risk of disputes with insurance companies. Providers are less likely to bill for services that aren’t covered by the patient’s insurance. Improved patient experience - Billing errors and delays are also major sources of stress for patients. The mismatch between estimated and actual costs is a common complaint. With 3 in 10 patients feeling unable to pay a $500 bill, providers must take steps to provide clarity around the billing process. Automated pre-service eligibility checks help to inform patients of their financial obligations so they can plan accordingly. The software can also support the delivery of tailored, proactive communications to patients, to avoid misunderstandings and queries. Patients are more satisfied with their overall payment experience, while providers see fewer payment delays. Increased revenue - The cost of eligibility errors goes beyond revenue lost through claim denials. If a patient’s insurance information isn’t checked properly, providers bear the financial burden of productivity losses, delayed patient payments, and reputational damage. Eligibility verification software can root out potential mistakes lurking beneath the surface so that claims and communications are correct the first time. By minimizing denials and helping to find missing coverage, this software maximizes reimbursement and accelerates payments. Optimized operations - As noted, using eligibility verification software instead of manual processes can result in significant productivity and efficiency gains. The CAQH reports that electronic eligibility and benefits verification could save medical providers 21 minutes per transaction, amounting to a potential cost saving of nearly $10 billion per year. Automation can release staff from time-consuming calls to insurance companies, reducing their workload and freeing them up to help patients with more complicated needs. This creates a positive patient experience while easing the pressures of staffing shortages. By improving overall revenue cycle management, verification software can increase financial stability. Key features to look for when choosing insurance eligibility verification software By now, most providers will be familiar with automation’s promise of speed, efficiency and accuracy.  To fully capture these benefits, providers should choose a software solution with certain key features. Real-time updates allow providers to confirm patient eligibility instantly, without falling foul of any changes to the patient’s coverage that could hamper reimbursement. For example, Experian Health’s Insurance Eligibility Verification solution connects with over 890 payers so providers can access up-to-the-minute eligibility and benefits data. Optimized search functionality increases the likelihood of finding a patient match. An optional Medicare beneficiary identifier (MBI) lookup service finds and validates MBI numbers, ensuring timely reimbursement, which is especially important as COVID-19 funding comes to an end. Next providers should look for a user-friendly interface. Insurance Eligibility Verification adapts responses from multiple payers so that registrars can access patient details in a consistent format, regardless of the original layout. Customizable alerts notify staff when action is needed. A major advantage of automated solutions lies in the possibility for more detailed reporting and analytics. A tool that synthesizes performance data can provide at-a-glance status updates for senior managers and help staff identify opportunities for improvement. Similarly, providers should look for a tool that fits neatly with their existing electronic systems and interfaces, to fully leverage data analytics and streamline operations. Integration with electronic health records can fast-track verification and registration by providing a single source of truth regarding patient information. Existing Experian Health clients will be able to access Eligibility Verification through eCare NEXT®, providing a single interface from which to manage several patient access functions. Automated verification: a smart investment? Rachel Papka, Director of Health Systems at Steinberg Diagnostic Medical Imaging says Experian Health’s eligibility products have helped her team to validate patient coverage in under 30 seconds: “The Eligibility and eCare NEXT piece allows us to see if the patient is eligible with the insurance they just presented quickly and in real-time – in under 30 seconds. As I'm facing the patient, I'm not hiding behind a phone. I'm not trying to log on to a different website. I'm literally interacting with the patient at the time of service with the eCare NEXT platform, and it's telling me their deductible or coinsurance or co-payments, and I can accurately collect from that patient right there. And it directly writes into my electronic medical record, so users only need to use one system.” For the 3 in 4 healthcare executives who said reducing denials was their top priority, automated insurance verification could be a wise investment. Find out more about how Experian Health’s health Insurance Eligibility Verification software could hold the key to streamlined claims management, fewer denials and faster cash flow.

Up to 15 million Americans may find themselves without healthcare insurance when the COVID-19 public health emergency (PHE) ends. The PHE has been renewed until January 11, 2023, and while further extensions haven’t been ruled out, the Centers for Medicare and Medicaid Services (CMS) has advised healthcare providers to prepare for a return to pre-pandemic rules. Looming uncertainty over coverage has consequences for both providers and patients. This article looks at what providers may expect as the PHE comes to an end, and specifically, how to proactively verify insurance eligibility to maintain cash flow and help patients navigate the changes. How will insurance coverage change when the PHE ends? Emergency legislation has required Medicaid and the Children’s Health Insurance Program to maintain continuous enrollment for the duration of the PHE. When the previous rules resume, states will have 14 months to process eligibility checks for Medicaid and CHIP enrollees. The US Department of Health and Human Services (HHS) estimates that around 8.2 million Medicaid enrollees will no longer be eligible for coverage. Another 6.8 million eligible individuals may lose coverage through “administrative churn.” Churn occurs when patients fail to provide annual confirmation of Medicaid eligibility. This can occur because of short-term changes in circumstances or because they don’t reply to or understand requests for information. Some patients will qualify for Marketplace tax credits under the Affordable Care Act and others may seek employer-sponsored coverage. But a large proportion may fall into the “coverage gap,” earning too much to be eligible for Medicaid, but too little to qualify for Marketplace credits. The Inflation Reduction Act of 2022 extends access to enhanced Marketplace provisions until 2025, which may bridge the gap for some. HHS lists a number of additional actions that may be taken at the state level to mitigate potential coverage loss. This includes the adoption of Medicaid expansion, outreach and engagement campaigns. It also includes investments in end-of-PHE preparedness, staffing capacity and in eligibility and renewal systems. What do these changes mean for providers? Providers must be proactive in managing the disruption that could occur when millions of patients lose or change coverage. If more patients are without coverage and unable to pay for services, this could lead to an increase in uncompensated care, which costs providers millions in lost revenue. The process of verifying insurance for those with coverage is likely to be more complex, which could also affect providers’ bottom lines. Changes can increase the risk of errors, which could lead to more claim denials. Longer verification checks may cause delays in patient registration and higher call volumes, creating extra work and stress for staff and a poor experience for patients. The end of the PHE may also affect access to vaccines and food benefits, both of which were expanded under the emergency legislation. These changes could lead to an influx in calls and queries which could compound pressure on staff. These staff pressures are a particular concern given ongoing hospital staff shortages. A possible surge in COVID-19 and flu hospitalizations over winter could ramp up the challenge even more. How can providers verify insurance eligibility? The process of verifying insurance eligibility and benefits involves confirming that: the patient’s insurance information is valid and current they’re eligible to have the services in question covered under their existing plan. A patient insurance ID card is useful, but it’s not enough to prove eligibility. Patient access staff will often check payer websites or call payers directly to verify coverage. This can be a time-consuming and laborious process. Some providers use clearinghouses to run these checks in batches. This can be more efficient than verifying each account in-house but usually takes time to receive confirmation. Another option is to deploy insurance verification software. Experian Health’s Insurance Eligibility Verification solution allows providers to confirm patient eligibility in real-time. The tool connects with over 890 payers to access up-to-date eligibility and benefits data. Responses from multiple payers are modified so registrars can view patient information in a consistent format. Staff gets notifications when edits or follow-ups are needed. The tool also checks self-pay patients against Medicaid databases, which will be invaluable when the PHE ends. Why are automated, real-time insurance checks so important? No one wants patient care to be delayed. By validating a patient’s coverage before the patient arrives, Insurance Eligibility Verification helps fast-track registration. Automated checks also ease the manual burden on staff and handle higher patient volumes more efficiently. This improves operational efficiency, increases cleaner claim submissions and accelerates reimbursement, creating a more satisfying patient experience. Patients will have a clearer idea of what they’ll owe at the time of service, leading to fewer payment delays. What else can providers do to close the gaps in health insurance coverage and verify insurance eligibility? Providers can streamline coverage checks by incorporating automated searches for any missing or forgotten active coverage. Coverage Discovery runs multiple checks throughout the patient journey, using proprietary data repositories, advanced search heuristics and matching algorithms to comb through government and commercial payers to find previously unknown insurance coverage. Fewer accounts end up going to bad debt or written off as charity. This maximizes reimbursement for providers, while reassuring patients who may have believed they were uninsured. A further step to ease the financial burden on patients and increase the likelihood of reimbursement is to combine these solutions with tools that give patients greater clarity about their healthcare bills. For example, Patient Payment Estimates offer patients clear and accurate estimates of their financial responsibility before they come in for care. Patient Financial Advisor provides personalized payment plans so patients can spread out payments in a way that works for them, together with easy payment methods. Find out more about how Insurance Eligibility Verification helps providers verify insurance eligibility, speed up eligibility checks, maximize reimbursements and ease pressure on patients and staff as the continuous enrollment provision unwinds.

COVID-19 provided an unexpected use case for patient portals. In a matter of weeks, the benefits of remote patient access were undeniable. Patient portals allowed patients to schedule, register and pay for care from the comfort and safety of home. Now, as the latest omicron sub-variant triggers another surge in case numbers, providers are again reminded of the value in making digital channels available to minimize face-to-face interaction. With staffing shortages continuing and patient numbers rising, it’s worth recapping the benefits of patient portals. Why should healthcare providers prioritize patient portals? Here are 7 reasons: 1. Patient portals can be used to communicate safely with patients as Covid-19 cases rise Health officials may be cautious about reinstating extreme measures in response to the latest wave of infections. However, they can’t afford to be complacent about an uptick in hospital admissions. Patient portals can mitigate the risks associated with increasing foot traffic by allowing patients to schedule and register for care without attending in person. Completing paperwork from home eliminates the need for patients to share clipboards or sit in stuffy waiting rooms, while online scheduling platforms enable staff to manage the flow of patients safely and efficiently. Remote patient monitoring, secure messaging and online prescription refill requests can also be managed via portals, further reducing the need for in-person visits. 2. They can ease pressure on understaffed teams Providers need to find efficient ways to handle the administrative workload that comes with higher patient volumes. It’s even tougher given increasing retirement and resignation figures. More nurses are embracing the occupational benefits of remote and virtual care and are opting to switch from high-stress facilities to telehealth positions. While this speaks to the growth and impact of remote healthcare, it leaves a gap to be filled in hospitals. Patient portals can alleviate some of the burdens by reducing the need for staff input at various points in the patient journey. For example, online scheduling reduces the number of calls to call centers. Pre-filled data and automated registration can reduce the risk of errors during patient intake, which are time-consuming to fix. Portals can also be used to help patients navigate the payments process, speeding up collections and reducing the time staff spend chasing payments. 3. Patient portals can address inefficient patient access workflows Because patient portals are tethered to the patient’s electronic health record (EHR), they provide a hub for every piece of data relating to the patient. Patients can access that golden record at any time. They get an engaging and transparent experience, and are less likely to call up to ask questions – they already have the answers. They can also check data to make sure that it's accurate, which helps avoid the delays and misunderstandings that cause friction for patient access teams. It's important to ensure that the portal itself doesn’t introduce friction. Patients need to be able to enroll in the portal without too much trouble. Automating the patient enrollment process and implementing a multi-layered identity-proofing solution can create a secure and efficient way for patients to get the most out of their portal, without compromising safety or efficiency. 4. To improve patient engagement and meet consumer expectations One of the biggest reasons to invest in patient portals is because patients say they want them. Research from Experian Health and PYMNTS found that 44.1% of patients have obtained test results through patient portals, while 18% used patient portals to fill out forms for their most recent healthcare visit. Overall, two-thirds said they use patient portals. Beyond offering a convenient patient experience, this is also a matter of patient loyalty and retention: 61% of patients say they’d consider switching providers to one that offered a patient portal, which could have a significant impact on revenue. 5. They can boost revenue by offering easy ways to pay Experian and PYMNTS research shows that around a fifth of patients uses their portal to make payments. Unfortunately, 16% of those patients said they’d faced difficulty viewing invoices, setting up payment plans and making payments through their portal, which suggests some room for improvement. Experian Health’s Patient Payment Solutions solves these challenges. A range of self-service, mobile-optimized tools simplify the patient financial journey by giving patients upfront pricing estimates, personalized payment plans and easy ways to pay. 6. Using patient portals can improve health outcomes (especially for “frequent flyers”) Patient portals also play an important role in promoting better health outcomes for patients. Research shows that when patients have access to their medical information, they feel empowered and prepared to speak to their doctor and adhere to care strategies. Multiple providers can engage with the patient through the same platform, and see what other treatments are being prescribed. This helps improve communication between the patient and provider and helps improve care management. It’s especially useful for older patients and those with chronic conditions. In this way, portals support effective care coordination, helping value-based care providers achieve their goals of reducing healthcare costs, promoting population health and closing the gaps in care that have widened over the last few years. 7. Patient portals can support compliance with price transparency regulations Finally, portals offer a route to ensuring compliance with new regulatory requirements around price transparency. The No Surprises Act and hospital price transparency rule call on providers to give patients accurate, upfront cost estimates so they can plan for their financial responsibility more easily. Patient Payment Estimates can be delivered in several ways, including through patient portals. And as noted, once the patient has their estimate, they can also be directed to easy and convenient payment methods, including through their portal. Whether it’s a surge in COVID-19 cases, rising inflation, or labor shortages, providers must find ways to build resilience, stay competitive, and continue to offer patients the flexible and transparent healthcare experience they desire. Patient portals should be part of the plan to open the digital front door. Contact us to find out how Experian Health helps healthcare organizations deliver a reliable and secure patient portal experience.

Dayton Children’s Hospital is a pediatric hospital in Ohio with over 300,000 annual patient visits. Ranked by U.S News & World Report as one of the top 50 pediatric facilities in the United States, the facility’s mission centers around providing “optimal health for every child.”  Challenges The Patient Accounts department, led by Richard Gonzales, wanted to reduce his team’s reliance on third-party collections agencies and avoid associated fees. This meant that his in-house team needed to further scale its operations and processes to reach their in-house collections goals. The Pre-Service Operations department, managed by Jason Schenck, pursued efficiencies for resources within the centralized scheduling team, including the goal to quickly respond to referrals and turning those referrals into scheduled appointments within 24 hours. Throughout the pandemic, both teams experienced staffing shortages and pandemic-related absences. Because their dialing methodologies were manual, these disruptions in personnel prohibited them from growing in-house collections and reaching the turnaround times Schenck's team wanted to achieve for scheduling referrals. As Dayton Children’s strived to achieve these ambitious goals, they decided to proactively provide a better patient experience through convenience, connection and an effective communication experience. Resolution Dayton Children’s launched Experian Health’s PatientDial solution in the Patient Accounts department to scale their in-house collections efforts, thereby reducing dependency on their outside collections agencies. The solution was also adopted in the Pre-Service Operations department to automate dialing and conversation readiness so that the team could expedite the scheduling of referred patients. The expertise of a dedicated Experian Health consultant provided unwavering support to the two departmental heads and also gave them full control over the operations to best match their expectations. Streamlining patient payment collections with PatientDial  The Patient Accounts department’s operations revolve around billing a claim, reducing bad debt, increasing patient collections and providing effective customer service. They devised a two-pronged approach when it came to contacting patients for payments. The outbound campaign focused on collections, whereas the inbound customer service team handled the large volume of incoming calls from customers and rerouted them to the correct department. When it comes to collections, the Patient Accounts department found that making phone calls was the most effective medium to support their collections efforts. Billing is a complex process and taking the time to connect with patient guarantors to explain those bills paid off. To refine the communication approach, patient accounts were segmented based on outstanding balance amounts and where they were on the statement cycle. Calls were then made to the accounts with the highest propensity to pay. Waiting on hold not only wastes a patient’s time but also leads to a frustrating patient experience. Many even abandon calls, to call again later, which makes phone lines even busier. To provide a better patient experience, the department was also able to try out an innovative recall campaign, enabled by the queue callback feature. Patients were called back automatically the moment an agent became available, thereby reducing call hold time. By providing patients with this callback option, Dayton Children’s is empowered to accept more inbound calls per day along with having empathetic conversations with guarantors around payment plans to sustain its collections goals. Patient scheduling and preregistration powered through automation The Pre-Service Operations department leveraged PatientDial to improve outbound call efficiency and optimize existing staff resources to schedule appointments rather than leave voicemails. The productivity for scheduling a new patient visit from an outbound call was about 30%. With the centralized team supporting more than 40 specialty clinics, the team needed to improve the number of new patient visits scheduled daily, which meant opening resources to receive inbound calls. The mighty team of 10 was able to strategically use the autodialer feature to make new appointments, send appointment reminders and schedule referrals. Time is of the essence in a healthcare setting, and swift access to pertinent patient information enabled the staff to start their work even before greeting the callers when an inbound call came. Powered by the agent pop feature, staff had immediate access to key patient identifiers such as name, date of birth and specialty clinic from referral. Additionally, the feature enabled the team to reinvest time in creating a positive patient experience through improved hold and talk times, both of which reduce the risk of call abandonment. Results of incorporating PatientDial With PatientDial, the Patient Accounts department has been able to successfully align revenue goals with employee productivity. Previously, the staff was able to make only 50–60 calls per day, out of which 70% went unanswered. By automating dialing, the staff is now able to make 600 calls per day, resulting in a corresponding uptick in collections. The recall campaign, used for following up with patient guarantors, was a new endeavor for the department and has reduced the staff’s burden of making 300 manual calls per day and has also reduced call abandonment rates. The Pre-Service Operations department, has seen a 50% increase in patient appointments scheduled, powered by 600–800 automated calls made per day. The referral-to-scheduled appointment timeline has gone down from 4 days to under 1 day. Two hundred patients can now be reached via text daily and the speed to answer calls has been reduced from 60 seconds to 30 seconds. Lastly, PatientDial has positively challenged the Pre-Service Operations department to rethink productivity and daily operational efficiency. Dayton Children’s investment in dialing automation has streamlined their patient communications around scheduling and far exceeded initial goals. Because of the resulting high volumes of new patients scheduled and improved efficiency and effectiveness the team realized, there’s a strategic plan specific to central scheduling and to implement standard processes for managing new patient referrals across the organization. What’s next for Dayton Children’s? Empowered by their stellar results, both the Patient Accounts and Pre-Service Operations departments want to further explore how PatientDial could help other departments achieve greater productivity and further deliver a positive patient experience. The Patient Accounts department wants to maintain its focus on productivity gains and employee experience through PatientDial, with the ultimate goal of bringing in more collections. The Pre-Service Operations department plans to take on additional scheduling responsibilities across departments, creating time to reinvest in direct patient care and improving patient outcomes. Initial plans are for establishing patient scheduling and improving processes to identify and schedule follow-up visits. Both the teams at Dayton Children's recognize Experian Health’s expertise in revenue cycle solutions, which has made this a successful partnership. Learn more about how PatientDial uses patient outreach and patient engagement processes and workflows to increase your bottom line.  

An efficient revenue cycle management (RCM) system is a win-win for patients and providers. Friction-free solutions that cover everything from booking appointments to paying bills create a more satisfying patient experience and allow patients to focus on their health. Providers can lower administrative costs and generate more revenue from data-driven billing and collections operations. To ensure the patient’s financial journey goes ahead without a hitch and avoid revenue leakage, the RCM system can’t skip a single step. Experian Health’s 10-step healthcare revenue cycle flowchart sets out the necessary ingredients for success. See the healthcare revenue cycle flowchart below: Step 1: Patient registration The healthcare revenue cycle flowchart begins with the patient’s first interaction with the healthcare organization. First impressions count. Patients want to be able to book appointments and complete registration quickly and easily, and providers that offer patient portals are seen as more attractive. Opening up the digital front door with online self-scheduling and self-service registration also helps providers increase operational efficiency and minimize manual errors that could lead to claim denials. Reliable patient intake software can verify patient identities, reduce manual processes and deliver a flexible patient experience – laying the groundwork for the entire RCM process. Step 2: Eligibility and benefits Next, providers need to check whether the patient’s insurance plan covers their expenses. To increase the likelihood of reimbursement, providers should give patients clarity about their coverage status and be vigilant about locating any missing or forgotten coverage. Coverage Discovery allows providers to check for undisclosed coverage at every patient touchpoint. By quickly uncovering previously unidentified coverage, bills will be cleared sooner with fewer write-offs to bad debt. This part of the RCM process is also a good time to help patients plan for their financial obligations. Patient Payment Estimates gives patients accurate estimates and links to financial assistance and easy payment methods, straight to their mobile device. With the right data and digital tools, providers can deliver a transparent, compassionate and convenient patient payment experience that encourages payment earlier in the revenue cycle and supports a healthy cash flow. Step 3: Data entry With RCM processes relying on data like never before, maintaining accuracy is paramount. Providers must be able to verify and protect patient identities to ensure the right information is linked with the right patient. Accurate data entry decreases the costs associated with medical billing errors, and improves interoperability as more patient data is created, collected and shared. A digital patient identification solution can build a single, accurate view of each patient, using a unique patient identifier to hold the information together like a golden thread. Automated patient enrollment using PreciseID® allows existing data to be auto-filled, while tools such as Universal Identity Manager maintains data in an interoperable format, to further protect against errors. Step 4: Prior authorizations Before treatment begins, providers must determine if prior authorizations are needed. If so, they must submit a request to the payer. Without prior authorizations, providers may see their claims denied, which increases costs, causes time-consuming rework, and creates a stressful experience for patients. With online prior authorizations, providers are guided through a workflow that automates inquiries, status checks and submissions. It auto-fills payer data using real-time information about each payer’s prior authorization requirements, stored in Experian Health’s pre-authorization knowledgebase. Prompts for manual involvement ensure the process is as efficient as possible, to expedite treatment and secure timely payments. Step 5: Patient encounter At the time of treatment, information about the services a patient receives will be added to their patient record. This sets the stage for accurate coding and billing. To ensure no essential information is omitted, providers must keep up to date with regulatory changes. For example, the Appropriate Use Criteria program introduces new requirements for providers ordering diagnostic imaging services. Providers should examine their workflows in advance to avoid any costly compliance errors. The patient encounter is also an opportunity to double down on creating positive patient experiences, and to anticipate any potential RCM issues. Communicating clearly about any changes to medical bills and checking again for coverage will keep the revenue cycle moving. Providers may also consider incorporating data on the social determinants of health to support efficient discharge planning and prevent high-cost readmissions. Step 6: Charge posting In the next step of the healthcare revenue cycle flowchart, providers must submit the claims to the relevant payer using the appropriate charge posting or charge entry process. Documentation must include a detailed breakdown of all the services provided to the patient, alongside patient information, history and insurance or payment plan status. Again, getting every detail right will secure more timely payments that match the expected amounts. Step 7: Coding and billing Before patient billing gets underway, providers must check payer codes for the services that have been delivered. Payers use diagnostic (Dx) codes, place of service (POS) codes, current procedural terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and others to determine payable amounts. If codes are not inputted correctly, claims are likely to be denied. Automated claims management software can check that every claim is clean and error-free before being submitted. Experian Health’s claims management software incorporates standard government and commercial payer’s global edits as well as client-specific customized edits so providers can submit claims with confidence. J. Scott Milne, Senior Director of Product Management at Experian Health, says providers can leverage tools such as Claim Scrubber and ClaimSource to automate and prioritize claims to maximize reimbursement: “Both of these solutions are focused on the most important revenue cycle goal – to submit the claim correctly the first time. With the combination of Claim Scrubber and ClaimSource, healthcare organizations give themselves the opportunity to decrease denial rates, increase cash flow and decrease the overall accounts receivables.” Step 8: Claims management After the claim has been filed, the payer’s claims adjudication process begins. Payers will check eligibility, benefits, coding and contract rules to determine their financial responsibility. They may decide to pay in full, pay a partial amount, or deny the claim, with the reasoning set out in an Explanation of Benefits (EOB) statement. If the claim is denied, the provider needs to decide if it’s worth reworking and resubmitting the claim. Rework is expensive and time-consuming, so many providers use a healthcare clearinghouse to check claims before they’re submitted. Providers may also consider using a tool like Enhanced Claim Status, which submits automated status requests based on payers’ individual timelines, and provides responses that include the payer’s proprietary codes and descriptions. This facilitates early intervention into claims that are flagged for denial, which improves productivity and faster reimbursements. Providers also get detailed denial analysis and monitoring reports to pinpoint the root cause of denials, so they can be fixed promptly. Step 9: Payer Contract Management The complexity and volume of payer contracts can leave providers with little negotiating power when it comes to querying and collecting underpayments and delays. Providers need robust processes to audit payer performance and keep track of changing payer requirements to ensure timely reimbursements. Experian Health’s Contract Manager helps providers stay on top of changes to payer payment policies, identify patterns of non-reimbursement, and appeal denials in the most effective way. It identifies inconsistencies between pricing claims and paid amounts, so providers avoid missed revenue opportunities. Positive provider-payer relationships make the revenue cycle management process easier for everyone. With reliable contract management tools, communication and two-way accountability are much more effective. Step 10: Patient Billing and Collections The final step in the healthcare revenue cycle management flow chart is to bill patients for the remaining amount they owe. Balances are collected by in-house collections teams or outside collections agencies. Revenue cycle management software makes this process smoother and more efficient. For example, Patient Financial Clearance assigns each patient to the appropriate financial pathway based on their individual circumstances, while Collections Optimization Manager can be used to build custom segmentation models and workflows. That way, resources can be focused on the accounts most likely to yield revenue. Then, once the patient’s bill has been issued, collections software can be used to create a compassionate and convenient payment experience and complete the revenue cycle. Find out more about how Experian Health’s Revenue Cycle Management Solutions help healthcare organizations deliver outstanding patient financial experiences, optimize RCM workflows and increase cash flow.