Understanding the Need for Eligibility Checks for Visits and Preauthorization for Procedures

While these activities oftentimes become challenging, they should help in facilitating reimbursement.

This month, we’ll dive into the next steps needed for medical practices to take after being credentialed to maximize the chances of receiving reimbursement. The next critical steps after getting credentialed are (1) to conduct eligibility checks for patient visits and (2) get preauthorization for procedures.

Why These Steps Are Important

One scenario where an eligibility check becomes useful is when a patient has an inactive or termed insurance. An eligibly check would help the front desk to ask the patient for alternative active insurance prior to the appointment. This quickly improves patient collection.

Likewise, eligibility checks help to identify those patients with high deductible plans. This helps anticipate a patient’s co-insurance and co-pay. When the co-pay is identified it can be collected upfront, rather than chasing the patient for payment afterwards (which is time consuming and inefficient).

But verifying eligibility and obtaining preauthorization can be challenging for healthcare practices for many reasons:

  1. They are time-consuming: Checking eligibility and obtaining preauthorization requires significant staff time and resources.
    The average time for clinic staff to conduct insurance eligibility checks or procedure preauthorization varies depending on the complexity of the insurance plan, the experience of the staff, the technology used, and the volume of patients.
    Generally, to complete the eligibility verification process, it can take anywhere from a few minutes to an hour or more.
    The preauthorization process takes even longer. On average, getting preauthorization can take anywhere from a few days to several weeks. Preauthorization requirements can be complex and time-consuming, and they may require multiple follow-up calls and documentation submissions.
  2. Staff resources: Some practices may have difficulty allocating sufficient staff time and resources to these tasks, especially in busy or understaffed clinics.
  3. Payer inconsistencies: Different insurance companies and payers have varying requirements for eligibility checks and preauthorization, which can make the process confusing and difficult to navigate for healthcare practices.
  4. Lack of payer transparency: It can be challenging for practices to receive clear and accurate information from insurance companies and payers regarding the status of their eligibility checks and preauthorization requests.
  5. Outdated office technology: An insufficient technology infrastructure can make it difficult for practices to obtain eligibility checks and preauthorization efficiently and effectively.

Specialty practices, such as cardiology for example, may face even more hurdles in obtaining preauthorization, including providing additional documentation by the specific specialty. 

Even though getting verification of a patient’s insurance eligibility and obtaining preauthorization prior to rendering services is burdensome and time-consuming, these steps are essential to ensuring predictable and timely reimbursement.

To expedite reimbursement, we must educate healthcare practices of the value to their practice of taking these steps by showing them the downside of not doing so.

  1. Patient dissatisfaction: A patient who arrives to the clinic expecting to receive treatment, only to be told their eligibility or preauthorization has not come through will lead to (a) lack of timely treatment (b) non-compliance (c) embarrassment of the patient, and (d) potential anger at the front office staff.
  2. Denied claims: If a patient is seen by the provider, but the patient’s insurance eligibility and/or preauthorization have not been obtained, the practice may be unable to receive payment for services rendered, leading to denied claims and a decrease in expected revenue.
  3. Delayed payments: If a claim is denied, the practice may need to resubmit the claim, which can result in delayed payments and disruptions to the revenue cycle.
  4. Increased administrative burden: The practice will need to spend additional time and resources to resolve denied claims and ensure that payments are received, which can increase the administrative burden on the practice.
  5. Revenue losses: If a patient’s insurance coverage and preauthorization requirements are not fully understood, the patient may be asked to pay out-of-pocket for services they believed were covered, leading to decreased patient satisfaction and likelihood of revenue losses due to non-collection.
  6. Increased risk of audits: Incomplete or inaccurate documentation, including failure to check a patient’s insurance eligibility and obtain preauthorization, can increase the risk of audits, which can result in fines and decreased revenue.
  7. Reduced capacity for patient care: If the practice is not able to effectively manage its revenue cycle, it may be forced to reduce its capacity for patient care, which can have a negative impact on patient outcomes and satisfaction.

To help medical practices head-off these issues, we need to advocate to medical practices the importance of building into their office policies a streamlined method for checking a patient’s insurance eligibility and obtaining preauthorization prior to rendering services. This way, medical practices can minimize these disruptions and ensure that their revenue cycle runs smoothly. But making these kinds of changes to regular office policies will take time.

To shorten the time, we at TiaTech recommend the following management practices:

  • Use technology-service solutions: newer technologies offering automation of eligibility checks and prior authorization approvals have considerable benefits: reducing manual tasks; identifying in advance termed insurance and high deductible plans; anticipating a patient’s co-insurance; and identifying co-pays, so collection can be made at the time of the appointment. Automation technologies cut costs and boost speed. Unfortunately, not all automation is created equal.
    Technologies that specialize in automating these RCM tasks, and do it effectively, empower the clinic and billing teams to stay on top of volume and reduce avoidable write-offs.
    When your system effectively initiates, statuses, and logs authorizations, you should see results. Do your research when selecting automation and it can pay off. Optimally, providers should see a 50 percent improvement in productivity, and a reduction of up to 54 percent in avoidable write-offs.
  • Make sure you have adequate staff and provide continued training and support
  • Work closely with payors to streamline the eligibility and preauthorization process

By addressing these challenges, practices can improve their financial performance and minimize the risk of revenue cycle losses.

Facebook
Twitter
LinkedIn

Susie Vestevich, Esq.

Susan A. Vestevich, JD, is the chief operations officer for Tia Tech (USA). She focuses on disruptive healthcare technologies and solutions, including new program rollouts as well as physician/client engagements.

Related Stories

Important Information Concerning Aetna

Important Information Concerning Aetna

Aetna’s recent policy update, which became effective July 1, marks a significant change in how the insurer will manage hospital readmissions. Previously, Aetna’s Diagnosis-Related Group

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Enhancing Outcomes with CDI-Coding-Quality Collaboration in Acute Care Hospitals

Enhancing Outcomes with CDI-Coding-Quality Collaboration in Acute Care Hospitals

Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.

November 21, 2024
Comprehensive Inpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Comprehensive Outpatient Clinical Documentation Integrity: From Foundations to Advanced Strategies

Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.

September 5, 2024
Advanced Outpatient Clinical Documentation Integrity: Mastering Complex Narratives and Compliance

Advanced Outpatient Clinical Documentation Integrity: Mastering Complex Narratives and Compliance

Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.

September 12, 2024

Foundations of Outpatient Clinical Documentation Integrity: Best Practices for Accurate Coding and Compliance

This webcast, presented by Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, a recognized expert with over 30 years of experience, offers essential strategies to improve outpatient clinical documentation integrity. You will learn how to enhance the accuracy and completeness of patient records by adopting best practices in coding and incorporating Social Determinants of Health (SDOH). The session also highlights the role of technology, such as EHRs and CDI software, in improving documentation quality. By attending, you will gain practical insights into ensuring precise and compliant documentation, supporting patient care, and optimizing reimbursement. This webcast is crucial for those looking to address documentation gaps and elevate their coding practices.

September 5, 2024

Trending News

Featured Webcasts

Patient Notifications and Rights: What You Need to Know

Patient Notifications and Rights: What You Need to Know

Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.

December 5, 2024
Navigating the No Surprises Act & Price Transparency: Essential Insights for Compliance

Navigating the No Surprises Act & Price Transparency: Essential Insights for Compliance

Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks.  Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.

November 19, 2024
Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Post Operative Pain Blocks: Guidelines, Documentation, and Billing to Protect Your Facility

Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.

October 24, 2024
The OIG Update: Targets and Tools to Stay in Compliance

The OIG Update: Targets and Tools to Stay in Compliance

During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.

September 19, 2024

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

👻Spooky Sale is Back!👻 Get 31% off all three Medlearn brands, using code SPOOKY24.