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The case for Insurance Eligibility and Benefit checks

Too often, medical practices find that they are losing revenue left and right and have no real idea as to why. As a natural reaction to this, practices begin to take drastic measures to ensure that they can collect on money that they are owed from insurance companies and patients. The truth is that a lot of the measures are reactionary and will not actually fix the underlying issues. It is rarely one single issue that causes a clinic to struggle, but a collection of small issues and inefficiencies. The sum of all of these issues can affect the financial performance of the clinic. Over the next month, this blog will focus on a series of discussions that can help you improve your clinic.

Recently, I followed a communication thread of a closed medical billing Facebook group. The initial question posed to the group asked what policy and forms people used to ensure that they could bill a patient if the insurance provided ended up not being active. Forty plus answers were posted and most described their forms and policies. The unfortunate thing with all of these answers is the fact that they were experts giving incorrect advice.

Instead of focusing on a fix, they were all discussing a reactionary measure to try and recoup money. This option will not help the issue because it will do nothing to fix future errors and denials.

The best solution to this issue would be to create a process that insurance benefits are checked before or at the time of service. Approximately 85% of total insurance denials are from eligibility, benefit or ID issues. By implementing this process, you can potentially decrease your total denials by 85%.

A PMR client had been plagued with eligibility and benefit errors; this problem and was averaging 300 plus denials a month. After taking over the process from the client, PMR was able to reduce the denials from 300 to 1 within the first month and by the second there were zero. The client has seen an improvement in the time that they get paid because, without these denials it takes less staff and time to collect on a claim because no additional research or rebill is needed.

Another point to consider is how well educated and trained are your staff that review eligibility and benefits. Data is only as good as the person who understands it. Frequently, clinic's that do check benefits still have inaccuracies because of the following:

1. Staff does not have training or background to read benefits from the payer

2. Staff does not have enough dedicated time to review all benefits for all appointments

3. Staff only relies on automated checks through EHR or practice management systems

If your clinic does not have a dedicated and trained staff member to review all benefits, your option can be to outsource. By doing this, you can rely on specialized staff to interpret all benefits and minimize staffing and payroll costs for your practice.

Remember, it is always better to implement solutions that fix the issue before it becomes a denial.

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