If patients cannot easily access care and coverage for care, hospitals struggle to deliver services and subsequently cannot generate revenue, thus resulting in uncompensated care.
Therefore, improving patients’ access to healthcare coverage is key to recovering funds owed for the care provided. For uninsured and underinsured patients, the most important prerequisite of access is identifying and securing appropriate coverage, in order to afford the medical care they need.
- Inadequate information collection during intake
At point-of-service, providers’ ability to capture reimbursement is at its highest. Inadequate data — including incomplete information from the payer or patient, lack of communication around procedures the patient needs, and insufficient screening for financial assistance or other program eligibility — ultimately affect providers’ likelihood of getting reimbursed for services delivered.
Additionally, uninsured and underinsured patients may not raise concerns about payment until additional tests or hospitalization are required, further increasing the cost of care. Getting all parties on the same page from the get-go helps ensure a positive patient financial experience while minimizing revenue loss.
- Relying on manual patient access workflows
Around half of denied claims occur at the front end of the revenue cycle. Some of the most common reasons for claim denial can be avoided simply by ensuring registration and eligibility verification are properly completed. Paper-based processes lack visibility into missing demographic information that can uncover alternative sources of coverage for the patient.
And with thousands of patient accounts to process, patient eligibility verification can be a daunting challenge for hospitals and health systems that rely on manual patient access workflows. Traditional approaches — including mailing statements and calling patients to follow up on bills — is extremely time consuming and labor intensive. Studies estimate that providers collect only one-third of patient balances larger than $200, with the rest being sent to collections or written off as bad debt.
- Inaccurate patient eligibility verification
One of the most common reasons why a claim gets rejected is inaccurate patient information, including misspelled names and typos in entering policy numbers, SSN and date of birth, or a misspelled name. Providers must also verify that the patient’s insurance is active at the time of treatment. To minimize claim denials later on, patient access staff must ensure patients’ eligibility for coverage at the time of appointment or perform a batch check prior to a patient’s visit.
Adequate training and expertise among patient access personnel is vital to ensure patient eligibility is verified in a timely and accurate manner. For example, there is a common misperception that all uninsured or underinsured low-income adults can receive health coverage through Medicaid, when, in fact, there are only a few eligible pathways available — and strict eligibility requirements makes Medicaid coverage difficult to keep. To maximize reimbursement and help patients identify the most appropriate coverage to best fit their unique needs, staff must keep up-to-date on a vast array of eligibility options for a complex range of available programs including:
- Children’s Health Insurance Program “CHIP”
- Hospital Presumptive Eligibility
- Medicare Savings Programs (QMB, SLMB, QI)
- Social Security Administration Benefits (SSI, SSDI)
- Behavioral Health Benefit Programs
- Coverage and Assistive Programs for NICU Babies
- Crime Victims Compensation
- COBRA Eligibility
- Veterans Benefits
- Indian Health Benefits
- Workers’ Compensation
- Motor Vehicle Accident Insurance
- General Liability Insurance
- Misalignment between departments
Revenue loss can be minimized by streamlining processes between front and back-office teams. At most healthcare provider organizations, departments work in siloes and do not act in unison even if they have the right resources. For example, in the case of uninsured patients, lack of information from patient intake to the billing office may lead to billers pursuing the patient and/or the wrong payer, only for the claim to be denied, as proper eligibility was not determined upfront. This can be prevented with better coordination of available coverage options and a keen understanding of the entire eligibility and enrollment process.
- Lack of patient enrollment assistance
A recent survey suggests that public understanding of available coverage options — and how to apply for them — is especially limited. Out of all respondents who received assistance in enrolling for coverage, 40% said it is unlikely they would have found coverage without help. The same survey also revealed that 12% of patients, or nearly five million people nationwide, tried to find help for enrollment but did not get it.
Healthcare organizations need to provide comprehensive eligibility and enrollment assistance programs to best improve patients’ access to coverage, which also leads to improved patient satisfaction and reduced bad debt, ensuring optimal reimbursement and enhanced denials prevention downstream.