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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1. Create Patient-Friendly Medical Billing Statements
Although medical practices and hospitals are aware of the complexities of the medical billing process, patients are likely to be perplexed. Industry expectations have shifted in such a way that providers must now take a patient-centered approach to this process, so it’s more important than ever to educate yourself on how to remain accessible.
2. Maintain a clean claim rate of at least 95%.
The clean claim ratio of your medical practice is the average number of claims paid on the first submission. In an ideal world, every provider would like to achieve a percentage greater than 95 percent, but the meaning behind the number is what truly matters. The higher your clean claim rate, the less time your staff will spend attempting to identify denial reasons, coordinate payments, and re-submit claims.
3. Don’t Ignore Payer Reimbursements Analysis
Many medical practices place too much trust in payers to reimburse them in full for every claim they submit. Regrettably, this is not always the case. Underpayments are more common than you may believe. Devoting resources to analyzing payment accuracy will reduce revenue loss while providing valuable insight into your practice’s revenue management cycle data.
4. Take Control of Your Accounts Receivable
How frequently do you keep track of your receivables? Do you find yourself pressed for time to respond to a denied claim? Perhaps you should reconsider how you handle contracts and receivables. Coding changes occur quickly in the healthcare industry, and there is no better time to prepare for potential issues.
5. Return to the Fundamentals of Revenue Cycle Management
Are you brand new to revenue cycle management? The first step is to have a consistent cash flow. Even if you’re well-versed in the complexities of medical billing and coding, it’s always a good idea to review your basic best practices to ensure you haven’t deviated from the path.
6. Submit Complete and Accurate Claims
Making sure your medical billing is correct the first time you submit it can save you the time and effort of editing and resubmitting incorrect claims. It is estimated that up to 80% of medical bills contain errors, resulting in weeks of editing, resubmission, and provider’s not receiving payment. Filling out claims correctly and avoiding common errors, such as incorrect patient or insurance information and duplicate claims, can help your medical practice have an efficient medical billing process.
7. Maintain Knowledge of Medical Billing Rules and Regulations
It is critical to be aware of the current medical billing rules in order to ensure best practices in medical billing and coding. Because regulations are constantly changing, staying informed can result in a more efficient process that avoids rejections and medical billing edits. Failure to stay current on medical billing rules can have a direct impact on the cash flow of your medical practice.
8. Always look for opportunities to improve.
Finding ways to improve will continue to help your healthcare practice grow. Because the healthcare industry is constantly changing, looking for ways to optimize the medical billing process on a consistent basis will help to maximize revenue. Aside from staying up to date on current medical billing regulations, tracking performance is critical for identifying inefficiencies and optimizing efficiency. Key performance indicators (KPIs) can help measure the accuracy and efficiency of previous performances and identify areas for improvement.
5 Medical Billing Tips for Your Healthcare Practice
- File claims on a daily basis
- Collect copayments at the point of service.
- Verify and update the patient’s insurance
- Keep track of unpaid claims and follow up on them.
- Make EOBs your friends
It is common to find a provider with excessive amounts in medical AR that are more than 180 days outstanding unless specific and consistent active accounts receivable follow up on current billings is initiated.
The volume of outstanding medical claims, as well as the time required to research, correct, appeal, and/or re-file the medical claims, will usually take much longer than anticipated. A small number of people devoted to this task will not be able to achieve the goal by significantly reducing/eliminating the claims. So outstanding AR teams will be able to collect as much money as possible in a short period of time.
Why is it Necessary to Have an AR Management Team for Healthcare Services?
In a healthcare organization, the accounts receivable follow-up team is in charge of investigating denied claims and reopening them in order to receive the maximum reimbursement from Medical insurance companies. Billing professionals with specialized skill sets are now required to handle AR follow-ups.
It should be noted that, in addition to AR follow-ups, several other critical processes, such as charge entry, verification, and payment posting, must be completed first. A medical billing specialist determines the exact procedure code and diagnosis code based on the treatment plan during these procedures. There is a chance that the medical insurance company will deny claims if they do not follow the rules; therefore, having a dedicated AR Management team who can follow-up with the Medical insurance firm to resolve your denied claims is critical.
Six Reasons Why AR Follow-up Is Critical in the Medical Billing Process
1. Financial Stability: The financial stability of any healthcare service provider is heavily reliant on maintaining a positive cash flow. The hospital must maintain a consistent flow of revenue to cover expenses in order to provide patient care services, and the AR department ensures that this is done.
2.Aids in the Recovery of Overdue Payments: AR follow-up assists all hospitals, physicians, nursing homes, and other organizations in recovering overdue payments without difficulty. It is easier for healthcare providers to receive payments on time when there is a team that is constantly involved in the claims follow-up procedure.
3.Reduce the amount of time that outstanding accounts are allowed to remain outstanding: The primary goal of the AR management team is to reduce the amount of time that accounts are allowed to remain outstanding. The AR team monitors unpaid accounts, determines the appropriate action required to secure payment, and implements payment procedures.
4.Claims Never Go Missing: The most common reason for payment delays is the claim not being received. This usually occurs when paper claims are misplaced. To avoid this, it is best to send the claims electronically.
5.Claims that are denied can be pursued: Depending on the reason for the denial, you can actually send a new claim request with the necessary corrections made. The AR department can ensure that all claims are followed through to completion by calling the insurance companies and obtaining the denial reason rather than waiting for the denial reason to arrive in the mail.
6.Recover Claims Held Pending for Information: Claims may be held pending for a period of time due to additional information required for the member. By following up properly, the AR Management team can inform the member about the situation and then take appropriate action to speed up the process to recover claims.
WWS medical AR programme solves the problems that have traditionally stymied individual providers’ collection efforts. WWS pursues these accounts by assembling a group of professionals to “blitz” them.
]]>There are several reasons why businesses in this arena can’t afford to put off cyber security measures and why tomorrow may be too late to do what you should have already done today.
When you think of ‘cyber security’, many of us automatically think of the business’s IT department, slaving away in hoodies in front of their laptops, processing code, putting up firewalls and scanning for viruses.
Information security is one of the few spots in the business where you can be involved in almost every part of the business.
To protect your practice from cyber security threats, it’s time to start thinking like a hacker. What sensitive, confidential or HIPAA data do you collect, store or transfer that could be compromised? And how vulnerable is that data to attack?
The majority of breaches in the U.S. affect small‐to medium‐size businesses:
• Lack of resources/funding for sophisticated IT security
• Lack of IT expertise
• 67% do not use web‐based security
• 61% do not use antivirus on all computers
• 60% of small businesses will go out of business within a year of having a major breach.
How to Assess the Cyber security Risk of Your Small Business
Creating a security risk profile can help you determine how vulnerable your business is to cyber attacks.
1. Assess your Risk
• HIPAA – Personal Health Information
• PCI-DSS – Credit Card Data
• PII – Personally Identifiable Information
• Health Insurance Information
• Proprietary Business Information
Don’t assume if data is offsite (Cloud), that it is any more secure
2. Secure Your Network
Managed Firewall Appliance
• Monthly or Annual Subscription
• Updates on a regular basis
• Detects anomalies
• Different from standard firewall
• Most Insurance Co.’s requiring these devices 5% VGM discount
Use 3rd party review of log files for added protection
3. Perform Vulnerability Scans
3rd Party Penetration Test (ethical hack
• Annual at minimum, quarterly ideal
• Reports low, medium, high
• Balance automated software vs. human
4. Software Patches/Updates
• Microsoft Patch Tuesday (Windows, Servers, Office, etc.)
• Upgrade software to latest version (Enterprise Management)
• Determine 3rd party software or use white list protocol
• Upgrade to Windows 10
99.9% of the exploited vulnerabilities (hacks) were compromised more than a year after being identified
5. Encrypt Mobile Devices
Minimal current hack threat, however likely the greatest risk
• Business Information on Mobile Devices (Email)
• Access to Network
• Access to Billing Software
• Stored Passwords
• Lost on a Regular Basis
Phones, Tablets, Laptops, Surfaces, I Pad Air Watch, Mobile Iron, MaaS360, Bit Locker
6. Protect Your Website
Typical Hacks to a Website
• Defacing – changing of content
• Phishing Pages – Fake PayPal, credit card, etc.
• Patient Information Stolen
• Credit Card #s
• Open Source Code (Joomla, Drupal, etc.)
• Low Cost mass produced sites are HIGH RISK
A hacked website tells referral sources and patients that you are not trustworthy
7. Purchase Cyber Liability
Currently Inexpensive Compared to Risk
• Insurance companies already requiring policies for referrals
• Use in RFP’s as a differentiation
• Creates best practices
Insurance companies often offer free advice
Why the Health Care Industry?
The health care industry has become one of the top targets for hackers.
• Health care data is rich with information hackers can make money on:
• Patient names
• Addresses
• Social Security Numbers
• Date of birth
• Insurance/Medicare ID
• Cell phone numbers
• Credit card/checking account numbers
• EACH of these data points is valuable on the cyber black market – together, they are a gold mine!
To Conclude
Cyber security is an ongoing battle, not a task to be checked off and forgotten about. New malware and attack methods consistently put your system and data at risk. To truly keep yourself cyber safe, you have to continuously monitor your systems, conduct internal audits, and review, test, and evaluate contingency plans
As you can see, there are many elements to consider when it comes to your practice’s daily cyber security status, and it’s not just your IT department’s responsibility to protect you.
For more information on how to handle a data breach get in contact with us at support@wonderws.com also check cloud date secure to minimise the risk of threat to your business.
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