Health insurance eligibility verification and the “Telephone” game, funnily enough, have a lot in common. Healthcare reimbursement laws are not etched in stone, and they are in constant change as systems mature. Individually, employers can change employee health plans, or employees can switch their plans. Ongoing patient eligibility verification among medical practices requires hawk eye precision if you don’t want to end up sending inaccurate claims to the payer.
Many medical practices prefer to outsource health insurance medical verification to ensure specialists are on the job and not be bothered with the cumbersome process associated with verification.
So now to the big question, how to choose the best insurance verification partner to trust with your practice’s most important business process – the first step of revenue cycle management?
Here are the questions to as.
1. Do they have specialty coders to take care of your specific coding needs?
Wrong codes account for up to 80% of rejected claims.
At the top of your must-have list for your medical insurance verification outsourcing company is to check if they have medical coding and strategies concurrent with the medical practice’s specialties.
If they have experience with a range of medical specialties, then they will know what to look for to submit clean and clear claims. The specialization range typically extends from dental and physiotherapy or radiology services to more highly specialized fields like gynecology or oncology.
This comes down to having certified coders for your medical practice’s specialized needs. Code checks should include
- ICD coding (diagnostic codes) that support CPT coding, since Insurance pays for procedures (CPT)
- CPT /HCPS code modifiers – 2-digit codes linked to CPT that provide evaluation and management during the office visit. Payers will use either a CPT or HCPS code. Billers need to be conversant with both.
- CPT / HCPCS code sequencing – codes on claims need to be sequenced from highest to lowest payment groupings
2. How informed are they about the major private medical insurance groups and Medicare and Medicaid?
When outsourcing medical insurance verification, the partner you choose should have a comprehensive understanding of the plans offered by private players as well as government-run programs.
Medicare is the same across states, while Medicaid varies from state to state.
If your insurance verification partner does not have experience with dealing with different insurance verification companies and plans, then the chances of errors in filing claims will be proportionally higher. An experienced partner will cut down on the processing time because they will know what to look out for when scrutinizing a patient’s insurance details.
3. How good are the shortlisted insurance verification companies at contract analysis?
It is not good enough to know about the major insurance payers and their plans, You must know how they change from state to state. States have a lot of control over what they want to be included in health coverage. Some states can provide extended coverage, while others might only cover the minimum that federal law requires as the basic.
Your insurance verification partner must demonstrate that they understand the variations in the state your medical practice serves.
4. Is the verification partner HIPAA compliant?
Any business associate in medical billing and health insurance verification must be HIPAA compliant. The addendum to HIPAA, with effect from 2013, makes business partners directly responsible for compliance and liable for violations.
Medical insurance verification, when outsourced, puts into the hand of a third-party, highly sensitive patient information.
HIPPA compliance by your partner is demonstrated by breach notification policies with all their employees and entities they work with to ensure the data’s privacy. They should also have software to perform risk assessment, audit reports, and tracking logs to ensure all activity is recorded and meet compliance regulations. They must also have adequate insurance verification training for their employees to ensure they know how to stay compliant.
Further, since HIPAA updates its policies regularly, the partner you choose to verify medical coverage should show their history, track changing regulations, to ensure they stay compliant in the future as well.
5. Do they have separate teams responsible for claims, rejections, and denials?
Choose a patient eligibility verification partner that has different teams to manage each aspect of the revenue cycle. This is because even the most efficient team will still see about 10% of claims rejected at the first pass. So, while new patients are entering the process, the team will still be working on rejected previous claims and outstanding balances.
A medical billing service is doing a good job when the provider can see an increase in their total collections and a regular cash flow. Separate teams are an excellent way to begin the engagement.
6. Why choose teams with stringent QA processes and transparent reporting?
Quality assurance checks that include random audits are crucial to ensuring optimal performance. Audits should be prospective (before claims are sent out) and retrospective. The quality report should track each team member to know what they must quickly improve on.
Audits can also determine outliers before large payers can flag them and mandate an internal audit.
Reporting gives visibility to the provider, but reporting should do more than that. Measures should be taken based on the reports to improve profitability. Monitoring denials and rejections can provide surprising insights. You may find that claim denials come from one particular payer or even a specific diagnosis code. Uncovering the reasons for denials can help increase clean claims submitted. And this falls into the outsourcing company’s responsibility, and you must ensure they have the processes in place for it.
Detailed reporting should provide the medical practice the ability to extract specific details from the report and build confidence in the reports’ accuracy. If they can juxtapose performance against industry benchmarks, that’s even better.
The medical billing process is complex, and insurance eligibility verification more so. The right third-party partner and best processes will ensure the optimization of cash flow. What must be kept in mind is that there will be an increase in cost with an increase in rendered services. Keeping the balance between the two is essential.
Tracking patient coverage, submitting clean claims, and documenting is made much easier with insurance eligibility partners that have proven expertise.
Our team works with multiple healthcare organizations throughout the US, across many medical fields.