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Top 5 Eligibility Best Practices

Brad Skelton, maxRTE Regional Manager


The revenue cycle begins with patient-facing tasks that have a huge impact on back-end claims management and reimbursement. One of the most critical front-end responsibilities is determining eligibility. It lays the groundwork for billing and collecting claims in the most efficient and effective manner possible by helping to prevent claim denials on the back-end.

Here are the top five eligibility best practices for improving revenue cycle management:

1.) Always ask to see insurance card and run eligibility checks at the registration desk.

Too often registration staff either fails to ask for insurance, or simply assumes prior coverage is still active. This misstep leads to an unnecessary, costly increase in self-pay accounts, or an increase in denials and additional collection costs. Each result leads to an increased workload for staff post-service.

2.) Train staff to properly read eligibility responses.

Many times patient representatives add a policy to a patient account, and that policy doesn’t carrythe benefits needed for a procedure. Training staff on how to correctly read eligibility responses is crucial. In addition, an eligibility platform that displays information in a format that is easy for staff to view supports this effort.

Failing to read/understand eligibility responses properly has a negative and sometimes costly impact on point-of-service collections (co-pay, co-insurance and deductibles). A well-trained staff can more confidently ask for payment at the time of service, without jeopardizing the patient relationship.

3.) Utilize an eligibility provider that also provides insurance discovery.

Utilizing an insurance discovery platform will locate any insurance coverages missed at registration, as well as any retro-approved coverages.

Use insurance discovery to save money by not having to pay an early-out vendor or collection agency because you found eligible insurance coverage instead of them. What’s more, insurance discovery can actually earn money by capturing accounts before they reach filing time limits and frees up financial counselors so they can focus on accounts in need of their assistance.

4.) Train staff to review patient financial responsibility when viewing eligibility response. Collecting co-pays, deductibles, and co-insurance prior to discharge impacts all areas of the revenue cycle. Staff’s abilities to read responses correctly and collect patient responsibilities are equally important. Patient responsibility that is not collected prior to discharge leads to an increase in patient statements generated, increased workload for early-out staff, and in many cases an increase in fees paid to early-out business office vendors.

5.) Partner with an eligibility provider that has a flat monthly fee model.

Too many providers pay eligibility vendors on a fee-per-transaction basis, or have entered into an agreement that limits the number of monthly transactions and imposes costly overage fees. This model is extremely challenging: 1) It is difficult to budget for when your organization is querying multiple payers to find insurance; and 2) Its high cost limits staff’s utilization of the system, leading to un-verified insurance coverages and costly back-end payment recoveries. Partnering with a vendor that offers a flat monthly rate ensures that staff can verify eligibility without limits at a pre-determined cost that is easy to budget for.

In order to accelerate the revenue cycle, you must receive prompt payment. But, this means great care must be taken to ensure you have processes in place to ensure eligibility up front to avoid the delay and expense of having to collect at the back end.