Claims & Contract Management

At the beginning of the year, the healthcare industry moved away from Medicare identifiers based on Social Security Numbers (SSNs), in favor of more secure Medicare Beneficiary Identifiers (MBIs). As with any large-scale change program, the shift was unlikely to be completely clear sailing. But with the coronavirus pandemic landing shortly after the 21-month transition period was due to conclude, the switchover has been rougher than expected. Impacted Care Care providers are discovering newly eligible Medicare beneficiaries who haven’t yet received their card, while existing beneficiaries have misplaced theirs. Without a valid MBI number, patients risk delayed access to care, while the admin process to sort it out can be stressful, especially for already-vulnerable senior populations. For providers, the extra work and delayed reimbursements are particularly unwelcome when COVID-19 is already putting pressure on services and squeezing revenue. Unprecedented intake conditions where staff and patients are trying to limit face-to-face contact makes it difficult to complete the usual coverage checks. As a result, providers are missing revenue opportunities they cannot afford, while incurring additional downstream costs when collections are delayed. Experian Health clients are optimizing Coverage Discovery to speed things up. Case study: how one healthcare provider is finding missing Medicare coverage faster For example, the southeast division of a national health care system, with 1700+ beds and $1.6B in revenue, needed better ways to find MBIs when Health Insurance Claim Numbers (HICNs) were phased out. Assisting Medicare patients with tracking down their MBIs was time-consuming and error-prone. They came to Experian Health to find a more efficient way to check Medicare coverage. Jason Considine, Experian Health’s Senior Vice President for Patient Collections and Engagement, says: “We knew we could help because we already had Medicare coverage history through our historical repository. As a test, we were given a control set of known Medicare patients without MBIs, and were charged with finding those patients’ MBIs and Medicare coverage.” Experian Health’s Coverage Discovery tool was used to batch-process the control set. This took less than a day, as the tool scans more than one million accounts daily, using historical and demographic data, synthesized with multiple proprietary data sources, to find unknown or forgotten coverage. In this case, the resulting data was collated via batch files, but could be integrated with other coverage and collections tools, such as eCareNext, which automates the more repetitive and hands-on pre-registration tasks. Coverage Discovery found 60% of the Medicare coverages with MBIs, plus additional coverages. This enabled the provider to file claims that would otherwise have been nearly impossible and very time consuming. The provider’s next steps will be to integrate Coverage Discovery with eCareNext, and roll it out to more of sites in the system. Could Coverage Discovery help your organization find missing MBIs? Capturing better insights into productivity, financial results, and staff workflows is always valuable. But in the current crisis, tool that maximize reimbursement and automating the tasks that take up staff time is essential. Through our historical data repository, Experian Health’s Coverage Discovery already contains many patient MBIs – and it’s continually updated. We can help you search for Medicare coverage and make sure your clients find their MBIs, easing pressure off your revenue cycle management teams during this extremely challenging time. Request a review of Coverage Discovery and improve your coverage and collections processes.

For many of the 36 million Americans who have registered for unemployment benefits during the coronavirus outbreak, losing their job means losing their health insurance. Options for the newly-unemployed are limited yet complicated: while the federal government has declined to reopen enrollment under the Affordable Care Act, several states are supporting those without coverage by opening emergency enrollment periods for state-based health exchanges. Those that can afford it may extend their existing employer plan through COBRA, while those that can’t may apply for Medicaid. But unfortunately, millions will be left without coverage. Now, with these changes happening in both large quantities and at rapid speed, the process for checking a patient’s coverage status is more complex, time-consuming and susceptible to errors than in normal circumstances. Further errors may appear as patients are forced to switch care teams, leading to disjointed care and incomplete, inaccurate or duplicate health records. It’s a huge administrative and financial burden for providers, who must keep pace with changes to the health insurance landscape or risk a surge in denied claims as a result of patient misidentification. How should they guard against patient identity errors and minimize revenue loss in the wake of COVID-19? How to prevent mismatched patient records and avoidable claims denials A 2018 survey found a third of denied healthcare claims were caused by patient identity errors, costing hospitals an average of $1.5 million. We may see this figure creep up following COVID-19, unless providers move quickly to implement robust identity proofing and patient matching processes. Providers looking to do this should consider prioritizing the following three areas: Eliminate errors during patient registration Up to half of denied claims occur earlier in the revenue cycle, which is also when most duplicate medical records are created. Improving identity proofing during patient scheduling and registration is a logical place to focus, to ensure records are accurate from the start. This should include proactively checking for active coverage as early as possible. Using a Coverage Discovery tool that automatically finds available coverage will help avoid bad debt write-offs and give patients peace of mind. Essentia Health’s Patient Access team were able to find 67% coverage pre-service, for patient accounts that were previously considered self-pay or uninsured. Automate identity matching throughout the revenue cycle When patient records are incomplete, duplicated or overlaid with part of someone else’s record, denied claims become an accepted cost – but they’re often avoidable. Instead of time-consuming and error-prone manual checks, providers should consider using automated identity management software to ensure patient records are accurate and complete. Data-driven matching technology supported by a Universal Patient Identifier allows a single view of each patient to be shared safely and securely across multiple healthcare services. There’s no need for tedious reconciliation work and providers can be confident they’re submitting clean claims each time. Improve identity management protocols for telehealth and mobile services More patients turning to telehealth services and patient portals to minimize face-to-face contact, putting pressure on providers to solve the patient matching problem. And with payers expanding coding for reimbursements for telehealth and remote services, there’s an added imperative to make sure patient information is accurate in order to minimize the risk of claims denials. Victoria Dames, Senior Product Director at Experian Health, says portal access has increased by roughly 40% since the start of the coronavirus outbreak, and explains that the rise in telehealth and mobile services means identity proofing must be a priority: “If you don’t already have identity proofing and automated solutions for patient matching in place, you’ll have duplicate records. We don’t want that – it’s important to have one view of the patient. But we need to move quickly. Automating for identity proofing eliminates the risk of human error and it’s faster too, which is crucial right now. We know many providers want to get their identity management and claims management systems optimized quickly, so we have a team set up to help.” Using the right technology to verify patient identities and analyze claims, avoidable denials resulting from missing or incorrect information can be caught sooner. Contact us to find out how we can help your organization manage patient identities to eliminate costly claims denials during and after COVID-19.

There’s a phenomenon in online product reviews where the customer seems to love their purchase, yet gives it only one or two stars. Why do they do this? Poor customer service: the item was delivered late, questions went unanswered, or payment processing was disorganized. When the consumer experience falls below expectations, the brand suffers – no matter how good the product. The same thing happens in healthcare. The clinical care may be outstanding, but if the patient finds billing frustrating or confusing, it’s those feelings they’ll associate with the overall experience. Many healthcare providers suffer reputational damage because the patient financial experience fails to match high quality clinical care. This is especially true for patients who find themselves without coverage and in need of financial assistance, which is often an extremely stressful process. And with unemployment levels soaring as a result of the coronavirus pandemic, it’s likely more Americans will need to explore eligibility for charitable support. Finding smarter, speedier and scalable ways to check charity care eligibility is even more important. Using automation for faster charity care checks Automation may be the answer. With a system that runs checks quickly and easily against vast databases of up-to-the-minute records, providers can discover a patient’s propensity to pay before treatment is even carried out. Clarity from the outset ensures the patient is put on the right payment pathway and lays the groundwork for a positive patient financial experience. Caye Mauney, Patient Access Director for Palo Pinto General Hospital, tells us how her organization used data-driven financial clearance checks to improve the patient financial experience and reduce bad debt: Speeding up checks for earlier eligibility decisions Prior to using automation, Palo Pinto General used a time-consuming and labor-intensive paper-based process to determine a patient’s eligibility for charity assistance. But with automated screening prior to or at the point of service, the hospital can now verify whether patients qualify for charitable assistance within three seconds, and quickly connect them to the right program. For those with a self-pay amount, a Healthcare Financial Risk Score can be calculated using historical payments information and credit history, to help determine the optimal payment plan. Mauney says: “All the information we need is now at our fingertips. The patient no longer needs to bring in check stubs or go back to a former employer to ask for information. It’s been a game changer.” Creating a personalized patient experience At Palo Pinto, staff wanted to make sure that patients were taken care of not only medically, but financially too. Just as each patient needs medical care tailored to their individual needs, so too should their financial accounts be handled on a case by case basis. With custom payment plans based on an individual’s unique financial situation, the payment process can be transformed into an experience that patients no longer dread or avoid. Automated patient clearance checks draw on multiple sources of data and run analytics to quickly determine the best option for each patient. It can also generate scripts for patient advocates to use, to help patients navigate the process more easily. Palo Pinto reports improvements in patient satisfaction and trust as a result of uncomplicating the patient experience in this way. Reducing bad debt and increasing point-of-service collections Seamlessly connecting patients to the right financial assistance program allows patients to focus on their treatment, while feeling reassured that their financial obligations will be met. For providers, swift processing means decisions are made quickly, resulting in fewer accounts receivable delays and a lower risk of uncompensated care. At Palo Pinto General, quicker charity applications means more are being approved, and therefore not written off as bad debt – ultimately helping their bottom line. Discover how automating checks for charity care eligibility with Patient Financial Clearance can help your organization increase productivity, improve collections and boost patient satisfaction.

There is no doubt the healthcare industry has taken a financial beating as a result of COVID-19. But there is a glimmer of hope for providers. Several new announcements were recently made attached to the Coronavirus Aid, Relief, and Economic Security (CARES) Act, specifically around reimbursements attached to COVID care for the uninsured. The financial stimulus, intended to stabilize hospital finances as providers face short-term revenue reductions due to the cessation of non-urgent procedures and the increased costs for personal protective equipment, has earmarked  a portion of the $100B established for CARES to reimburse healthcare providers at Medicare rates for the treatment of uninsured COVID patients. The guidance does not indicate specifically how much money will be set aside to reimburse these claims. The big question? How long will the funds last and how quickly will providers act? With both unemployment, translating into more uninsured individuals, and COVID cases on the rise, the dollars could be exhausted quickly. A recent study by Kaiser estimates the total payments to hospitals for treating uninsured patients under the Trump administration policy would range from $13.9B to $41.8B. While Medicare payments are about half of what private insurers pay on average for the same diagnoses, estimates surrounding COVID care can be in excess of $50k for those severe cases where struggling patients spend weeks in the intensive care unit on a ventilator. Bottom line, it’s likely the funds will be distributed quickly, especially when factoring in unemployment skyrocketing. As of April 30, more than 30M Americans have filed jobless claims amid the coronavirus outbreak. The all-new portal opened on April 27 for sign-ups, and providers can begin submitting claims electronically on May 6. Healthcare providers who have conducted COVID-19 testing of uninsured individuals or provided treatment to uninsured individuals with a COVID-19 diagnosis on or after February 4, 2020 can request claims reimbursement through the program electronically and will be reimbursed at Medicare rates, subject to available funding. A complete list of FAQs regarding the CARES Act and reimbursements are accessible on the Health Resources & Services Administration website. But what other tips and considerations should providers contemplate as they attempt to get their fair share? Here are three actions to optimize a provider’s chances of claiming reimbursements for the uninsured. Automate the insurance check. Providers must attest that they have checked for healthcare coverage eligibility and confirm the patient is uninsured. If they fail to check, they may be denied. Providers must verify that the patient does not have coverage such as individual, employer-sponsored, Medicare or Medicaid coverage, or any other payer options that will reimburse for the COVID-19 testing and/or care of that patient. There are ways to automate this step, completing a second eligibility check to attest that the patients have no coverage before providers submit claims to the government. Scan for the social security number (SSN), if possible. While there may be instances where COVID patients entered a facility and were quickly admitted with no formal registration process, the CARES Act states an SSN and state of residence, or state identification/driver's license is needed to verify patient eligibility. If these pieces of information are not captured, providers need to attest that they have attempted to capture this information before submitting a claim. The patient may be long gone, but there are still ways to attempt to retrieve a patient’s SSN after they have exited the healthcare facility. Providers should know that claims submitted without an SSN and state of residence, or state identification/driver's license may take longer to verify for patient eligibility. Again, with the possibility that these funds could quickly be exhausted, it is in the provider’s best interest to submit claims that are as clean and validated as possible. Act fast. Recall the Small Business Administration's Paycheck Protection Program (PPP) — a coronavirus relief fund for small businesses that was also established under CARES? The $350B allocated by the bill was quickly depleted in days. While these funds were going to individuals in entirely different industries, there is no concrete projections on how long healthcare providers can expect the $1B fund to cover reimbursements for the uninsured. So, providers need to act now, and fast, by tapping into automation and auditing solutions that will optimize their chances of securing their fair share.

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