Tag: healthcare reimbursement

Since 2000, US hospitals have provided nearly $745 billion in uncompensated care. Many contributing factors lead to revenue losses. However, incorrect or missing patient insurance information is often a top culprit. Providers don't have a complete picture of a patient's coverage when active benefits are incomplete or unknown. The result? Insurance denials, time wasted on resubmissions and increased bad debt. In today's complicated healthcare environment, disjointed insurance verification processes often make it challenging for providers to find hidden coverage. Changing payer requirements and ever-evolving regulatory changes also make checking active coverage tricky. To protect profits, organizations must remain vigilant when finding all available patient insurance coverage to pay for the cost of care. Adopting technology, like automated coverage discovery solutions, can help providers accurately and quickly determine what insurance a patient has, if any, and what it covers. This article takes a deeper dive into some common insurance discovery challenges providers face and how Experian Health's Coverage Discovery® helps streamline the process and reduce revenue losses. Why insurance discovery matters A healthcare organization's financial performance hinges on accurate insurance billing and claims processing. Insurance discovery helps employers find missing coverage quickly and maximize reimbursement. However, providers often don't have the correct insurance information. Missing coverage is cited as a top reason for claim denials for nearly 20% of providers, according to data from Experian Health's State of Claims 2024 survey. Patients may enroll in a new employer plan, move to a new state, switch jobs or have other factors affecting their coverage. Changes can happen at any stage in the patient journey. In some cases, patients may not be aware of what's changed. Evolving payer policies also result in altered or expired benefits, further complicating matters. Common challenges in insurance coverage identification Insurance coverage identification is a necessary part of revenue cycle management, but isn't always a streamlined process. Some of the common challenges providers face during coverage discovery include: Incomplete insurance information Missing or outdated insurance information affects all aspects of the revenue cycle, from claims processing to bill payment. However, it's common for patients not to submit their complete insurance information to providers or forget to update paperwork after initial registration. Patients often don't know their coverage status or are unsure how much of their healthcare costs are paid for by insurance – especially Medicare beneficiaries. When providers fail to spot incomplete or inaccurate patient insurance information, it leads to coverage gaps, claims denials and unpaid medical bills. Heavy manual workload for administrative staff With healthcare organizations already feeling the squeeze of continued staffing shortages and rising operational costs, providers can't afford to waste valuable staff time. Unfortunately, manual insurance coverage identification processes are typically time-consuming and error-prone. Phoning payers, logging into multiple portals and manually entering patient data places added burdens on staff. In many cases, providers only learn that a patient's active benefits have changed after the claim has been submitted. Correcting errors takes time, with 43% of providers reporting that they need at least 10 extra minutes to check eligibility after an incomplete initial check. Changing payer requirements and new regulations During coverage discovery, providers must consider payer requirements and regulations. However, it's not always easy for staff to stay on top of ever-evolving payer requirements and new healthcare industry regulations. During coverage discovery, providers often manually gather information from multiple databases and may miss important updates or have incomplete or inaccurate coverage information. How insurance discovery typically works When a patient seeks care, providers use health insurance discovery to check whether a patient has active insurance and confirm coverage details, like plan type and payer name. The coverage discovery process helps providers know if a payer will cover planned services and ensures the cost of care is billed to the correct payer. It's also common for a patient to have more than one active plan. So coverage discovery typically involves cross-checking payer databases to verify that no coverage is missed. In cases where a patient doesn't have insurance coverage, providers can use insurance discovery to check a patient's Medicaid eligibility and charity support options. Successful revenue recovery starts with a patient engagement strategy that simplifies the steps to reimbursement at every patient touchpoint. A three-pronged approach can increase the likelihood of payment by identifying the opportunities to check for coverage before the patient comes in for care, at the time of service, as well as after care. 1. Pre-service insurance coverage checks Verifying and tracking the patient's insurance status before they come in for care means their financial obligations will be clear from the start. Advanced knowledge makes it much easier for patients to plan – and pay ­– their medical bills. An automated coverage identification solution such as Experian Health's Coverage Discovery solution can scan patient information as soon as they schedule an appointment to find any previously unknown coverage, using multiple proprietary databases and historical information. 2. Identifying coverage at the point of care When the patient receives their treatment, Coverage Discovery can check for any billable commercial and government coverage that may have been missed during pre-service. Integration with eCare NEXT® and HIS/PMS platforms provides on-demand insurance coverage scans at the time of service. Providers should also give patients opportunities to pay for care at this point too, to avoid the need to chase for payments later. A simple and quick payment experience can reduce the risk of additional A/R days and collections agency fees. 3. Post-service checks for unidentified coverage Finally, for any accounts that haven't been settled at the point of care, providers should run further coverage checks before determining whether to send statements and payment reminders to the patient, write the amount off as bad debt, or engage a collections agency. Coverage Discovery can detect any discrepancies that could lead to denied claims. This solution scans patient balances in A/R for active insurance coverage 30, 60, and 90 days post-service. It also offers weighted confidence scores so that accounts are reclassified and rebilled appropriately. Automated scrubbing can eliminate manual processes so staff can use their time more efficiently. Coverage Discovery also does a final scrub scan on patient balances before sending accounts to collections, or writing off to charity or bad debt. These steps will help plug revenue leaks at every stage of the patient journey, improving cash flow, reducing the risk of bad debt, and creating more satisfying patient experiences. How insurance Coverage Discovery benefits healthcare providers In 2023, Experian Health's Coverage Discovery successfully tracked down previously unknown billable coverage in nearly one-third of patient accounts, resulting in more than $25 million in found coverage. Providers seeking to maximize revenue can benefit from automating the insurance discovery process with Coverage Discovery. Here's how: Quickly find missing insurance coverage in real-time Experian Health's Coverage Discovery helps providers catch outdated insurance information and locate missing coverage early. This helps ensure changes to a patient's benefits are caught before a claim is submitted. With real-time access to multiple proprietary databases – like employer information, historical search information, registration history and demographic validation – providers can proactively identify billable Medicare, Medicaid and private insurance options. Needing only minimal patient details for a search, Coverage Discovery instantly locates additional primary, secondary and tertiary insurance. See it in action: How Luminis Health used Coverage Discovery® to find $240K in billable coverage each month. Eases administration burden on busy staff Heavily manual processes and outdated insurance information cost providers time and money during insurance discovery and throughout the revenue cycle. Coverage Discovery streamlines discovery behind the scenes and saves staff time by running continuous checks throughout the patient journey. When staff isn't bogged down with tedious insurance discovery processes, they can focus on more complex tasks and providing quality patient care. See it in action: How UCHealth secured $62M+ in insurance payments and saved $3.5M+ in 2022 with Coverage Discovery. Reduces the likelihood of claims denials Claim errors, such as the wrong payer information or coverage information, often result in delays, denials or bad debt. However, when insurance discovery is automated with a solution like Coverage Discovery, the process is faster and no longer relies on error-prone manual tasks.  Providers benefit from cleaner claims, a more streamlined claims submission process and quicker payer reimbursements. Choosing the right automated insurance coverage discovery solution Experian Health's comprehensive coverage identification solution, Coverage Discovery, helps providers make the reimbursement process easier to navigate and reduces the burden on front and back-end staff. This automated solution is capable of operating at every touchpoint of the patient journey, from registration to collections. Learn more about how automated health insurance discovery helps providers reduce claim denials, improve cash flow and deliver better patient experiences. Learn more Contact us

“Experian Health’s speed and ability to speak our business language definitely impressed us,” said ACS president, Tim Anderson. “Some of the claims were valid for only a few more weeks, and we were able to submit them in plenty of time. This is the best, fastest platform we’ve seen to reconcile duplicate and data-deficient records. It really helped us achieve the best possible resolution for our clients and our company.” Acadiana Computer Systems, Inc. (ACS) was contracted with numerous labs in Louisiana to submit billing claims, primarily to Medicare, for testing that occurred in the first months of the pandemic. Unfortunately, in the chaos and scramble to offer testing services as quickly as possible in nursing homes and testing sites, the labs struggled to collect needed information to submit valid claims – in particular the Medicare beneficiary’s MBI number, or even a Social Security number. As the pandemic response progressed, a similar challenge developed around the administration of vaccines, particularly in mass vaccination sites and other off-site vaccination centers. Providers struggled to get more than a name and maybe a birthdate, address, or phone number. This left a gap in ACS’ efforts to submit private insurance and Medicare reimbursement claims on behalf of their clients. ACS worked with Experian Health and our Universal Identity Manager (UIM) platform, delivering the Experian Single Best Record (ESBR) – the matching of records through aggregation of disparate information and delivering a single record that accurately identifies separate records that belong to one person. The platform uses multiple data sources to verify, match and consolidate disparate records into one “best record.” ACS assembled the records requiring more identifying data and prepared them for secure transfer to Experian Health. Experian Health securely accepted more than 75,000 patient records and ran them through the UIM platform in 24 hours. It was critical to assign an SSN to as many individual records as possible, and to confirm an associated MBI number for Medicare billing, if applicable. Results included: 69% assigned unique records 12% identified as duplicate records With the information delivered back from the matched records, ACS had all the necessary data needed to continue the billing process. Within a week claims were submitted, expected to exceed $20 million in collections when the process is completed. The ACS group was experienced, savvy and data ready. Their expertise enabled an elegant and efficient exchange and complemented Experian Health’s capabilities. ACS expects to continue to use Experian Health’s UIM platform throughout the pandemic and also for mitigating duplicate records and preparing claims for submission. Learn more about how our Universal Identity Manager (UIM) platform can help your organization eliminate duplicate patient records.