Don’t wait to revamp insurance verification

Healthcare reform makes processes for insurance verification a top priority for patient access areas, says Sebrena Johnson, manager of insurance verification and precertification in the Admission Services Department at Cone Health System in Greensboro, NC.

“It will be more important to get all verification and authorizations prior to patients getting admitted, because of financial responsibility,” she says. “If this is not obtained, there could be penalties or complete denial of claims for very critical and expensive visits.”

Cone Health System recently made very significant changes to its insurance verification processes, reports Johnson. “We have just begun implementing the Epic system where all parties — the hospital, medical records, and doctor’s offices — are working together with one patient and one medical record,” she says. “It has required a new way or thinking for all parties involved.”

The new system gives patient access staff a fuller picture of the patient’s care, but extensive training was needed. “Some people were nervous and fearful of the unknown. It required everyone pulling together and filling in for others while they were training,” Johnson says.

Patient access staff members need a thorough understanding of the different types of insurance plans, knowledge of the requirements for each plan, and the ability to maintain good relationships with insurance providers, advises Johnson. “There is an easier notification process when all information is properly obtained on the front end,” says Johnson. “The new process has also required that we have more coverage to make the notifications in a timely manner.”

Continual checking

At Geisinger Health System in Danville, PA, members of the patient access staff do insurance eligibility checking during all phases of the process, says Angela Long, associate vice president of administrative services in revenue management. These steps are taken:

• Staff check the patient’s insurance during the scheduling/registration process.

“We do this in real-time for close-in/same day services or in batch mode a few days in advance of the service being rendered,” Long says.

• Insurance verification is sometimes performed during the visit with a referring provider or specialist, to determine if a test or service being ordered will be covered by a patient’s insurance plan.

“This upfront verification of insurance helps not only the organization, but also the patient. They will know upfront if there are any issues with coverage,” says Long.

• For patients classified as self-pay at the time of service, staff run batch insurance eligibility transactions against Medicaid’s database to determine if the patient has since qualified for insurance through that plan.

• Staff verify insurance when following up on an outstanding insurance balance to determine if the correct payer was on file when the claim originally was submitted.

• Staff run batch eligibility processing in between the appointment or service being scheduled and the actual date of service.

“We create worklists for instances where the insurance that is listed is not valid and/or the patient is not covered by that particular plan,” says Long. This information is trended to determine if a particular employee is struggling with data capture of insurance.

“We then reach out to the user and provide an overview of how to process insurance correctly,” says Long. “If the issue continues in that particular area, we work with their manager and suggest the user go through re-training.”

• Insurance eligibility verification is integrated within technology systems throughout the revenue cycle process.

“We not only run files through automated batch insurance eligibility processes; we have also built work-lists and rules to be sure that exceptions are routed to the most appropriate resource at the most appropriate time,” says Long. (See related stories on identifying trends, below, and offering price estimates online, 104.)