What is patient eligibility?

Eligibility simply refers to a patient’s right to receive healthcare benefits. When you sign up for a new healthcare plan, you will be asked to provide information about yourself including your age, date of birth, current address, etc. Based on this information, your insurance company will determine your patient eligibility, that is, what healthcare services you are entitled to receive as a patient. If you are eligible for services, your insurance company will determine the amount of money you have to pay out of pocket for your healthcare services. If you are not eligible for services, you will not receive any healthcare coverage.

Eligibility for in-network services and providers

Every insurance plan offers a network of healthcare providers and services. This means that you will only be offered a selection of vetted healthcare providers, such as medical doctors, specialists, surgical facilities, and pharmacies nearby your home address. The network is made up of healthcare providers who have agreed to offer services to patients at a certain rate. This rate is often lower than the standard rates offered outside of a network. While in-network services and providers are provided at a lower rate, if you decide to visit an out-of-network provider you will have to pay the entire cost out of pocket. This is because your insurance company will not reimburse you for services you receive outside of your network.

Eligibility for out-of-network benefits

Some insurance plans will offer you out-of-network benefits even if you decide to visit an in-network provider. This means you will still be able to be reimbursed for services received at an out-of-network provider. However, you will pay a higher out-of-network fee than if you had received the service in-network. You will also have to submit a claim to your insurance company and wait for them to approve your claim before receiving reimbursement. Depending on your insurance plan, you might be allowed to visit an out-of-network provider after a certain period of time has passed. This is known as a “waiting period.” You will have to pay the full cost of the service out of pocket until your insurance company approves your claim.

Understanding your plan’s deductible

A deductible is the amount you have to pay out of pocket before your insurance company begins to reimburse you. As a patient, you will have to pay this amount every year before your insurance company will start paying you back. After you have paid your annual deductible, your insurance company will begin to reimburse you for any expenses you have incurred. Depending on your insurance plan, you might have multiple deductibles, that is, one for in-network and one for out-of-network services. With some insurance plans, after you have paid your deductible for in-network services, you will only pay a coinsurance rate for the remainder of the year. With others, you will continue to pay a coinsurance rate for out-of-network services.

Understanding your co-pays

A co-pay is the amount you have to pay for a specific service at the time of treatment. These services include visits to the doctor, medical tests, or prescriptions. Depending on your insurance plan, you might have to pay different co-pays for different services. Depending on what your insurance plan requires, you might have to pay a co-pay at the time of service or you might have to pay a co-pay at the end of the year. At the end of the year, you will have to pay the total amount of all the co-pays you have accrued over the course of the year.

Summary

When it comes to healthcare benefits and eligibility, the more you know, the better. Understanding your eligibility, what your plan offers, and how you can use it to your advantage is essential. It will also help you better understand what sort of healthcare options are available to you, how much they cost, and whether or not you qualify for certain services.

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The most recent MGMA stats poll indicated that 50% of medical practice leaders said their days in A/R increased in 2021, compared to 15% who reported a decrease, and 37% who said they remained the same. (MGMA conducted the poll on November 9th, 2021, and received 587 responses.)Practices know that the longer a medical bill goes unpaid, the more difficult it becomes to collect. According to a report by Forbes and Debt.com, half of Americans are in some kind of debt for medical expenses (57% owe at least $1,000)

The receivables are grouped into “aging buckets” of 0 to 30 days, 31 to 60 days, 61 to 90 days, 91 to 120 days, and 121+ days. MGMA DataDive Cost and Revenue estimates that the median amount of A/R over 120 days in multi-specialty practices is 13.54%.

According to the survey, practices identified several key factors that contributed to the increase in A/R days:

• Limited office staff to handle outstanding debts
• Training of new employees can be arduous
• In an Aug. 24 MGMA Stat survey, 54% of medical practices reported credentialing-related denials increased in 2021 as a result of questionable denials and delays.

What Needs To Be Prioritized

• Establish billing guidelines and a process for collecting unpaid balances
• Establish systems for collecting past-due balances 
• Communicating with the patient is extremely important (especially if they need assistance in understanding the portion of the bill they are responsible for or their deductible)
• Providing payment options helps reduce bad debts and prevents them from being referred to collections
• Regularly run A/R reports and deal with denials immediately
• Coding is essential to every aspect of RCM
  • The staff should be coding experts, and they should educate the providers whenever possible
  • All encounters should be closed on the same day (not more than 72 hours after a visit)

According to an American Medical Association poll performed in 2017, 84 percent of survey participants assessed the burden of prior permission on physicians and personnel as high or extremely high. According to other research, doctors spend an average of 20 hours per week and over $83,000 per year engaging with insurance companies. These figures will continue to grow as the incidence of prior authorization requirements rises.

Prior authorization begins with physicians long before the procedures of RCM services. It is a difficult process that takes up a significant amount of physicians’ productive time, which might be better spent on providing better patient care.

However, unless there is significant prior authorization change in the healthcare sector, providers must continue to obey the criteria established by payers. Here are six measures that provider organizations may take right now to simplify the prior approval process.

Understand what is necessary. Check the authorization requirements before providing treatment, especially for procedural and surgical procedures. Examine and use available payer coverage determination criteria and/or medical policy guidelines to proactively submit required information on the first try.

Make the most of your resources. Create and use EHR clinical templates tailored to individual payers and procedures to ensure proper capture of the clinical documentation requirements required for approval.

Reduce the number of steps in your procedures. Direct your initial efforts on the top 10 to 15 payers. Create informational summaries for each (particular requirements, preferred method of contact, etc.) that are easily available to staff. Track your prior authorization filing and associated results with a simple spreadsheet.

Play it smartly. Prior authorization requests and accompanying documents must be submitted in the proper format. only provide what is necessary. Establish clear policies, time frames, and processes for follow-up. Create and keep standard letters of appeal on hand for use in the case of a refusal.

Examine and evaluate prior authorization monitoring data by payer to have a better understanding of what types of care are at risk of refusal. Determine any disparities in staff approval rates.

Implement operational improvements that focus on best practices for successful submissions. By following these industry standards, health systems may improve the speed of the prior authorization process while reducing the strain on clinicians and staff. These measures help decrease the risk of patient care delays, operational roadblocks, and rejections.

In the RCM business, there are several efficient methods for improving prior authorization. Regular monitoring of operations, and medical equipment that require prior authorization, as well as implementation of the most recent technical standards for PA, will aid in optimizing pre- authorization.

WWS has extensive access to cutting-edge tactics for establishing and documenting your prior authorizations. Our skilled staff will manage your whole payroll process and assist you in meeting your company objectives.