the importance of insurance verification, fee transparency ... · the importance of verification...
TRANSCRIPT
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The Importance of Insurance
Verification, Fee Transparency and
Bundling
Helen Lowenwirth, MBA, CASC
Administrator
East Side Endoscopy, LLC
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East Side Endoscopy, LLC
� New York State Certified Ambulatory Surgery Center / AAAHC accredited
� Single Specialty Endoscopy (soon to be Dual)
� Affiliated with Mount Sinai Beth Israel
� Performed its first procedure in January 2010
� 10,000 Procedures Annually
� 23 owner physicians with independent practices serving the community
� 31 credentialed physicians performing procedures
� Medical Director is Dr. Brett Bernstein
� We have a very successful Charity Program and have performed over 600
free screening colonoscopies as part of the NYC Department of Health-
Community Cares Project
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The objectives of this presentation
� To explore what insurance verification really means and why it is so
important.
� How it can impact your operation, profitability and improve overall
operations.
� Recognize the increasing importance of fee transparency to patients.
� Talk a little about “bundling”.
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Verification Defined
The process of establishing truth, accuracy or the validity
Insurance Verification - Is the process of checking patient’s insurance coverage and benefits prior to date of service to insure
payment for services
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The Importance of Verification
� Why is verification so important ?
It is a critical component of revenue cycle management
� Claims will be paid if conditions for coverage are met…
� Insurance is inforce
� Premiums are paid
� The service is covered
� Deductibles have been met
� If it is medically necessary
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The Importance of Verification
• When should insurance be verified ?
� Every time the patient makes an appointment
� And Again on the Date of Service
� And Again for a follow up
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Gatekeepers
� Who Verifies ? The front office is your gatekeeper!
� Verification is the responsibility of the front office..
� Should be done at the time of scheduling
� Most verification is done on-line
� By the time your billing staff gets it ..it is too late
� Verification should be done AGAIN at the date of DOS
� Copy of card
� Address
� Other ID
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“ But I have insurance !” ….
� What do we Verify?
� Eligibility
� Coverage/Benefits
� Policy Limitations
� Financial Responsibility
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“ have you met your deductible” ….
What do we verify?
� Eligibility:
� If the coverage is in force (effective date)
� Premiums are paid
� Coverage:
� Is it a covered service (i.e. well exams, sick visits, maternity, etc. )
� Who is the Subscriber (Patient, Spouse)
� Primary vs. Secondary
� In Network vs Out of Network
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… they paid the last time I was here” ..
What do we learn when we Verify?
� Policy Limitations:
� Preventative services
� Contracted services
� Are pre-authorizations or pre-certifications required
� Pre-existing
� Patient’s Financial Responsibility:
� Co payments
� Co insurance
� Deductible
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Why are claims Denied
� Demographic Data
� DOB doesn’t match
� Subscriber # missing /invalid
� Group # missing or invalid
� Coverage terminated
� Eligibility
� Not eligible at DOS
� Pre-Authorization/ Precertification is (was) required
� Authorization timed out
� Non- Covered Services
� (some carriers require waivers for these so you can bill patient)
� Medical Necessary
� Reasonable, necessary for the diagnosis, injury or disease
� (do you have the documentation)
� Coordination of Benefits
� Primary vs Secondary
� Liability Carrier
� Worker comp/No fault
� Missing or Invalid Codes
� Timely Filing
� No Referral on file (from PCP)
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Life Cycle of an Endoscopy Procedure
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1. Patient makes appointment
Verify eligibility and benefits at physician
office
3. Physician recommends
procedure
4. Procedure
is scheduled/Instructions
5. Insurance cycle
6. Pre-call7. Appointment
Confirmation
8. DOS
9. Post- call /follow up
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Billing Process
Make an appointment
Eligibility
Pre-registration Verification
Coverage
Pre-certificationVerify Pre-certification
Review with patient /Discuss
financial responsibility
DOS Rerun!
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Verification Process
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1. Patient makes appointment
Verify eligibility and
Benefits
3. Needs referral /pre-certification
call patient /referring physicians
5. Obtain authorization
Verify authorization
Call patient to review financial
responsibility
DOS
Collect co-pay
9. Submit Claim
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Fee Transparency
Providers are collecting a increasingly higher share of fees from
patients.
Driving more of a consumer oriented approach to obtaining services
Patients are asking “how much is this going to cost ME”
� High deductible Plans
� Co-pays/co-insurance
� Ancillary services (anesthesia, pathology, labs, imaging, etc.)
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Determining Patient Responsibility
� Discussing money is never easy, especially in healthcare situations
� Patients do not (even try to) understand their insurance coverages
� We must educate our patients about their policies and coverages
� Staff must be trained to answer patient questions
� Access to fee schedules to calculate co-insurances
� Make the calls to determine remaining deductibles
� Call in advance to advise patients of their responsibility
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Determining Patient Responsibility
The consequences are real
� For Providers
� People postpone treatment
� Don’t take medication
� For Patients
� Increasing bad debt for providers
� Increasing patient (consumer debt)
� 20% of adults struggle to pay medical bills
� 3 out every 5 bankruptcies due to medical bills; one study 62% with 78% having insurance
� Leading cause of bankruptcy; more than job loss, overuse of credit and divorce. or
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Data Elements in a chart
• Name, Address, Telephone, e-mail, SS#, DOB, DOS, Emergency Contact, Employer
Demographic
• Policy #, Group #, Subscriber #, PCP, Referral, Pre-authorization – aka- pre-cert, Verification, Eligibility, Benefits, Primary, Secondary, Active Coverage, Benefits, Deductible, Co-pay, Co-insurance, Out of Pocket, Stop Loss, Insured, Relationship to Insured, Guarantor, Claim, CPT, ICD-9 (now ICD-10) Bills, Statement, EOB, Collection.
Insurance
• Symptoms, consult notes, H&P, Indications, NPO, BMI, Medications, Allergies, Advance Directive, Glucose, BP, prior surgeries, do you smoke ?, do you drink ? Implants ? Dentures,
Clinical
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The anatomy of a visit
• A
• Insurance Eligibility and Verification of benefits
• Advising patient of financial responsibility,
• Collecting $$$$$
• Pre- assessment
• Consenting
• Pre-Op Care
• Post- Op Care
• Discharge
• Follow up call
• Consultation
• Preparation instruction
• H & P
• Diagnosis
• Treatment Plans
• Risks & Benefits
• Advance Directives
•Family members
• Insurance
•Work /School
•Transportation
•Escorts
Social Physician
Insurance RNs/ NPs/ PAs/Techs
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Bundling
Links payment for multiple services/providers
Seek out more efficient facilities (ASC vs hospital/OBS)
Cost control
Accountable for outcomes
Assuming risk on following and ancillary services
Reinforces Compliance
Quality Improve
ment
One Fee
Inclusive of all ancillary service
“no surprise bills/
Transparency
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Bundling
More conducive to some procedures where an “episode of care” can be clearly defined
from beginning to end.
� Colonoscopy
� Joint Replacements
� Cardiovascular
� OBG
Key Factors
� Must know your cost
� Assume Risk
� Shared Savings
� Relationship of Multiple parties
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Conclusions
� Insurance Verification is a critical component of revenue cycle management
� The current environment is very complex with many factors working against
healthcare providers to collect payments
� Being proactive and transparent helps manage patient expectations and
compliance with financial responsibility
� We have to start looking at services that are conducive to fee bundling.
Proactively discuss with payers to promote cost control and efficiency and
quality of care.
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Thank you !
Helen Lowenwirth, MBA, CASC
Administrator
East Side Endoscopy, LLC
www.esecgi.com