Many registrars have excellent eligibility verification software at their disposal. Still, some responses are interpreted incorrectly.

“Even though hospitals invest in technology tools, we are still faced with end user interpretation,” says Rachel Spoerr, director of patient access at University Hospitals Cleveland (OH) Medical Center.

Two factors make it harder to determine eligibility: lack of standardization of health plan insurance cards and inconsistency in the way returned results are formatted. If insurance is verified incorrectly, it sets into motion multiple problems. No one notifies the payer of the patient’s admission status within the required 24 hours. Authorizations and precertifications are missed. Bills are sent to the wrong payer.

“The patient could be out of network with no coverage or limited coverage, and increased out-of-pocket liability,” Spoerr adds. All these mistakes end the same way: The claim is denied.

To keep it from happening, the hospital gives registrars plenty of exposure to all kinds of insurance coverage responses. During training, new hires take turns acting as patients. “They enter information in the registration application and receive responses from carriers,” Spoerr says.

Staff quickly realize how complicated it is. To be sure they understand properly, new registrars shadow experienced colleagues for three to six weeks. “Insurance verification is very complex. There are hundreds of different plans,” Spoerr notes.

Usually, the problem is payer responses are incomplete. Eligibility responses from one large payer state coverage is “active,” but fail to flag the patient’s out-of-network status. This causes huge problems for the hospital. “The only way we know the patient is out of network is the presence of a tiny logo on the insurance card,” Spoerr notes.

If the patient does not present the physical insurance card, there is no way to tell until it is too late. “Patient access is uninformed, and payment is compromised,” Spoerr explains.

Other “active” coverage responses do not reveal the patient only carries vision benefits. “Patient access must understand how to read insurance cards and interpret contract status,” Spoerr stresses.

Limited benefit plans with $100 or less per day inpatient coverage are becoming more common, too. The system does not flag the sparse coverage. “We must be very diligent to review all of the details,” Spoerr says.

Misread eligibility responses mean surprise bills for patients, something nobody wants. “It creates rework for billing, denials, and ultimately loss of revenue,” says Maryann Heuston, senior director of revenue cycle access operations at Cambridge Health Alliance in Malden, MA.

Some payer sites go down frequently, adding to the problem. Even if the sites are working correctly, eligibility responses can be deceiving. “Some responses say that the patient was eligible. But when you read the fine print, they really weren’t eligible,” Heuston says.

This happens with MassHealth (Massachusetts’ Medicaid and Children’s Health Insurance Program). Responses come back saying the patient is “eligible.” Farther down in fine print, the response specifies the patient is “covered for dental services only.”

To registrars, it looks like the patient is fully covered by Medicaid. “The quick reaction by the front-end user is to put that in as the coverage and move on,” Heuston says.

Patients may carry old cards that are no longer valid. Health plans make changes restricting coverage during open enrollment periods. Either way, says Heuston, “people assume they are still covered for a particular service, but they no longer are.”

Too many claims are denied because of these mix-ups. “We worked with our vendor contacts to come up with a way to alert the registrar that the patient is not covered for the medical visit,” Heuston says.

After a system redesign, registrars receive more details on what is really covered. “It makes it easier to interpret so it’s not a claim going out the door, and then we get the denial,” Heuston says.

The system even tells registrars the specific action that is needed to confirm the patient’s actual coverage. “It is quite unique,” Heuston reports. “It will improve the accuracy of the data we are collecting related to insurance. We think this is groundbreaking.”