Denial Management & Patient Payment Experience

Increased regulation, value-based care, and skyrocketing patient payment responsibility means practices have more pressure on revenue than ever before. In a time when staff is being asked to do more with less, practices need a way to eliminate outdated, manual processes and leverage the right technology to improve efficiencies and customer satisfaction.

The eligibility—denials connection

Searching for information on payer websites, or spending hours each day on the phone with payers, takes time and resources many offices simply don’t have. Yet failure to confirm coverage on each patient can trigger denials. In fact, missing or incorrect eligibility information is one of the top reasons claims are denied.1 And since denied claims represent 90% of missed revenue opportunities, it is clear that eligibility verification is essential to a practice’s bottom line.2 But how can you find time to rework denials if you can’t find time to verify eligibility? It’s no wonder many practices choose to work only the highest value denied claims.

Dealing with denied claims is not only a challenge for your staff and a drain to your bottom line; denials can also negatively impact patient satisfaction. Imagine receiving a bill for services you know should be covered. Learning that they were denied due to an error at the office may cause undue tension with their provider, as well as undue stress on their finances. It may also result in added collection costs or write-offs.

Automating the benefits verification process can help many practices avoid denials while freeing staff to help with important tasks like checking patients in or taking payments. Fortunately, there are several automated eligibility verification solutions on the market and most are easy to use, so there should be a minimal learning curve for staff.

The best eligibility solutions are those that are automated directly from the PM/EMR. Many practices will configure their PM/EMR to run a batch eligibility file before they leave for the day, so tomorrow’s patient roster is ready for them when they return the next morning, showing the full day’s schedule. While reviewing the list, missing information can be more easily flagged for follow-up when the patient checks in. Many practices run batch requests for patients with recurring visits, which also helps save time for providers and their patients.

In short, automated eligibility solutions help streamline workflows and reduce labor-intensive processes. With batch and real-time options, you won’t need to ask most patients for their latest insurance information; you’ll already have it.

The patient payment experience—redefined

The proliferation of high deductible health plans (HDHPs), now at nearly 40% of covered individuals, means a greater percentage of a practice’s revenue comes directly from patients.3 Ensuring patients pay their full responsibility at or before the time of service—or at least make arrangements to pay—is more critical than ever for helping practices sustain optimal cash flow. But that can be difficult when neither the patient nor the practice knows before time of service what the patient will owe.

Traditionally, it’s been difficult to predict patient payment responsibility for a given service. Information about variations in coverage policies and uncertainty about where patients stood in relation to their annual deductible, either wasn’t available or was difficult to find. Consequently, practices collected only co-pays at the time of service, and then billed for the remainder at a later date.

For patients, this lack of transparency around patient responsibility can cause “sticker shock” when they receive a bill for more than they expected. Being caught off guard can understandably upset patients and lead to them to call the practice to question their bill. Staff is caught in the middle, wanting to help the patient understand but still needing to request payment.

New estimation technology is now available to help improve patient cost transparency. Estimates are generated with a level of detail that enables both the practice and the patient to better understand what patients have left on their deductible and what portion of a procedure will be covered. Providers can print and share a copy of the estimate at or before time of service. Having this information up front enables patients to make more informed decisions about their care and gives them the opportunity to proactively determine how they will pay.

Patient responsibility estimation tools enable providers to take an educational—not adversarial—role in patient collections. And when patients know their providers are willing to share this information, it can enhance patient satisfaction and loyalty.

Success Story

A small family medicine clinic in the Midwest was struggling with denials, write-offs and getting patients to pay what they owed. The practice began using Revenue Performance Advisor from Change Healthcare. With Revenue Performance Advisor, the practice streamlined its eligibility verification process and saw denials tumble by 27%. They also used the patient responsibility estimation tool available within Revenue Performance Advisor and saw collections increase significantly, with more than 75% of patients making payments while still in the office.

With Revenue Performance Advisor, the group’s practice manager was able to reengineer workflows by eliminating repetitive tasks so staff could work more efficiently. These improvements enabled the reassignment of a billing team member to the front desk to assist with check-ins and patient payments.

The time to act is now

Leveraging technology to streamline workflows can help reduce cashflow bottlenecks like denied claims, while optimizing patient collections. Removing time-consuming manual tasks helps relieve stress on the staff. And when patients know their provider is doing everything they can to improve the patient experience, it can enhance patient satisfaction and loyalty.

1. Kevin Fuller, “Top 5 medical claim denials,” Healthcare Finance, July 31, 2013, http://www.healthcarefinancenews.com/news/top-5-medical-claim-denials
2. John Andrews, “Visibility key to efficient revenue cycle management,” Healthcare IT News, September 16, 2010, http://www.healthcareitnews.com/news/visibility-key-efficient-revenue-cycle-management
3. Morgan Haefner, “CDC: Nearly 40% of US adults have high-deductible health plans,” June 7, 2017, https://www.beckershospitalreview.com/payer-issues/cdc-nearly-40-of-us-adults-have-high-deductible-health-plans.html