February 7, 2007
Eligibility verification has always mattered. But it matters even more now because of the changes in healthcare insurance, from consumer-directed plans to pricing transparency. With the changes occurring in the health insurance arena, eligibility is becoming a wave that will force its way through healthcare organizations with disastrous results if not prepared for. Unfortunately, eligibility verification is one of the most neglected elements in the revenue cycle. An article in the November 2006 hfm magazine discusses the urgent need for seamless, integrated eligibility and benefit verification, as well as steps every provider organization should be taking to prepare for standard, automated eligibility verification.
The Ripple Effect:
In the absence of proper eligibility determination, countless downstream problems are created: delayed payment, rework, decreased patient satisfaction, increased errors, and, potentially, nonpayment. Incomplete eligibility verification creates problematic ripples in three key areas:
> Plan identification
- Erroneous plan billing
- Failure to identify out-of-network patients
- Failure to meet correct plan's timely filing requirements
> Benefit coverage
- Inability to identify excluded benefits
- Inability to determine benefits requiring pre-certification
- Failure to preauthorize with correct plan
> Patient satisfaction
- Incorrect filing of claims
- Inability to verify insurance benefits with initial registration information
- Incorrect identification of patients' financial responsibilities
The First Step toward Improvement
How can your organization avoid these problems? There are several steps that will help:
- Gain internal management commitment to improving eligibility automation to enhance the organization's financial performance and patient satisfaction.
- Approach potential business partners. Providers cannot achieve the vision alone; they depend on health plans and software vendors.
- Ask your partners what they are doing to make seamless eligibility verification a reality. Make ongoing business relationships contingent upon partners supporting standard electronic commerce for eligibility and benefit verification.
- Ask your health plans when they plan to adopt CORE, a collaboration of nearly 100 healthcare industry stakeholders brought together by the Council for Affordable Quality Health Care's Committee on Operating Rules for Information Exchange to develop a set of enhanced, common operating rules for electronic eligibility and benefit verification, and become CORE certified. Consider requiring CORE certification as part of your managed care contracting expectation of preferred plans.
- Talk with your software vendors, including scheduling, registration, and billing companies, to identify their plans to obtain CORE certification. Ask what they are doing to incorporate eligibility verification into their software workflows.
- Consult with your clearinghouse to determine whether it plans to become CORE certified.
- Become a CORE endorser to show your organization's commitment to improved performance in this critical business process. Also, consider getting involved in CORE; its work groups will continue their work to build on this initial foundation with further data content and functionality.
Most centralized verification offices and third-party data management companies do not cost-effectively address the need for consistent, timely, and robust information incorporated into providers' workflows. Only by transforming the entire process into a seamless, standard, electronic interchange can we achieve the reduced costs and improved patient service demanded of us today.
SOURCES:
Additional Resources:
Education:
If you have questions or comments about HFMA Wants You to Know, contact editor Maxine Harrison.
HFMA Wants You to Know ISSN: 1540-0697. Volume VI, Issue 3. Copyright 2007, Healthcare Financial Management Association. All rights reserved.