The Importance of Insurance Verification, Fee Transparency and Bundling. Helen Lowenwirth, MBA, CASC Administrator East Side Endoscopy, LLC

Transcription

1 The Importance of Insurance Verification, Fee Transparency and Bundling Helen Lowenwirth, MBA, CASC Administrator East Side Endoscopy, LLC

2 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 ,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 2

3 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. 3

4 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 4

5 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 5

6 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 6

7 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 7

8 But I have insurance!. What do we Verify? Eligibility Coverage/Benefits Policy Limitations Financial Responsibility 8

9 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 9

10 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 10

11 Why are claims Denied Demographic Data DOB doesn t match Subscriber # missing /invalid Group # missing or invalid Medical Necessary Reasonable, necessary for the diagnosis, injury or disease (do you have the documentation) 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) Coordination of Benefits Primary vs Secondary Liability Carrier Worker comp/no fault Missing or Invalid Codes Timely Filing No Referral on file (from PCP) 11

12 Life Cycle of an Endoscopy Procedure 1. Patient makes appointment 6. Pre-call 7. Appointment Confirmation Verify eligibility and benefits at physician office 5. Insurance cycle 8. DOS 3. Physician recommends procedure 4. Procedure is scheduled/instructions 9. Post- call /follow up 12

13 Billing Process Make an appointment Pre-certification Verify Precertification Eligibility Coverage Review with patient /Discuss financial responsibility Pre-registration Verification DOS Rerun!

14 Verification Process 1. Patient makes appointment Verify authorization Call patient to review financial responsibility Verify eligibility and Benefits 5. Obtain authorization DOS Collect co-pay 3. Needs referral /pre-certification call patient /referring physicians 9. Submit Claim 14

15 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.)

16 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

17 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

18 Data Elements in a chart Demographic Name, Address, Telephone, , SS#, DOB, DOS, Emergency Contact, Employer Insurance Policy #, Group #, Subscriber #, PCP, Referral, Pre-authorization aka- pre-cert, Verification, Eligibility, Benefits, Primary, Secondary, Active Coverage, Benefits, Deductible, Co-pay, Coinsurance, Out of Pocket, Stop Loss, Insured, Relationship to Insured, Guarantor, Claim, CPT, ICD-9 (now ICD-10) Bills, Statement, EOB, Collection. Clinical Symptoms, consult notes, H&P, Indications, NPO, BMI, Medications, Allergies, Advance Directive, Glucose, BP, prior surgeries, do you smoke?, do you drink? Implants? Dentures,

19 The anatomy of a visit Family members Insurance Work /School Transportation Escorts Consultation Preparation instruction H & P Diagnosis Treatment Plans Risks & Benefits Advance Directives Social Physician RNs/ NPs/ PAs/Techs Insurance Pre- assessment Consenting Pre-Op Care Post- Op Care Discharge Follow up call A Insurance Eligibility and Verification of benefits Advising patient of financial responsibility, Collecting $$$$$ 19

20 Bundling Cost control Links payment for multiple services/providers Seek out more efficient facilities (ASC vs hospital/obs) Quality Improve ment Accountable for outcomes Assuming risk on following and ancillary services Reinforces Compliance Transparency One Fee Inclusive of all ancillary service no surprise bills/ 20

21 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

22 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.

23 Thank you! Helen Lowenwirth, MBA, CASC Administrator East Side Endoscopy, LLC