Back-End Revenue Cycle Management — The Importance of Eligibility Verification and Detection

Playing Detective: Who’s Got The Coverage?

A crucial aspect of the healthcare revenue cycle is the process of determining which party or parties are responsible for payment. This entails a complex series of questions and answers that starts when a patient makes an appointment and may continue for months after services have been rendered.

Insurance eligibility verification happens at points all along the revenue cycle, and providers with proactive, efficient processes in place for identifying coverage from the outset stand a greater chance of delivering a seamless experience for their patients. But increasingly complex systems of billing and coding, combined with narrowing submission windows demanded by insurers, creates a number of obstacles to effective, timely collection.

Getting a handle on your eligibility verification procedures can result not just in an improved bottom line but in a better experience for patients. In this article you’ll get an overview of coverage eligibility and learn how Nemadji’s proprietary Eligibility Detection service addresses key issues in coverage determination and revenue realization.

Front-End Detection: Sooner Is Better

Most providers are hyper-focused on front-end verification, investing heavily in software that ensures collection of as much accurate info up front as possible. Administrative staff go through the initial phase of determining eligibility when they establish contact with the patient, book the appointment, and contact the insurer. Ideally, the administrator creates an account or patient profile at the outset, helping stave off ambiguities down the road. Automated, real-time eligibility software at the point of service can help reduce AR days by preventing later denials and rejections. As Beverly Hospital’s Gary Marlow, Vice President of Finance, explains,

“The last thing you want is getting a claim submission kicking back to them, then having to work their way through the institution. If you get the information up front in as pleasant a manner as possible, it saves heartache for the patient and family if the claim is processed and cleared in a judicious manner.”

Providing convenient payment options and on-target cost estimates up front can also assist with revenue-loss prevention. In particular, cost estimates have proven effective in helping patients plan and prepare financially, helping reduce collection costs.

Back-End Detection: It Ain’t Over ’Til It’s Over

While the importance of identifying coverage up front cannot be understated, it is just the first step in a complex process of revenue cycle management. Of the many revenue cycle tasks facing healthcare systems and hospitals, back-end insurance eligibility verification may in fact be one of the most important, albeit time-consuming aspects of the healthcare revenue cycle. Unfortunately, many healthcare systems and hospitals overlook or simply ignore key aspects of back-end verification and detection due to their time consuming and complicated nature. This is a mistake; data matching and eligibility detection in particular are crucial to both the healthcare revenue cycle and a healthy bottom line.

Nemadji’s Eligibility Detection service supports hospitals and healthcare systems by focusing exclusively on these back-end efforts, reviewing patient accounts for eligibility across Medicare, Medicaid, and commercial insurance after discharge. This process involves a combination of automated and manual efforts to uncover missing or unknown coverage, translating into increased revenue for hospitals and other healthcare providers.

Back-end eligibility detection like Nemadji’s differs markedly from the work of collection agencies. Rather than targeting patients, our specialists look to recover owed revenue from institutional payors. Nemadji employs a multi-faceted approach, incorporating analytics-based discovery tools and software as well as manual support, coupled with a commitment to go deeper and further back in time than other vendors are able to go.

Zeroing In on Closed Accounts

Patient accounts that are closed can be a rich source of untapped revenue for hospitals that have robust back-end detection in place. Accounts may sometimes be deemed closed, with a zero balance due from the patient, when providers have yet to receive full reimbursement from responsible payors. In such cases, instituting “zero-balance reviews” may be helpful in realizing the earned revenue.

Similarly, Nemadji’s Eligibility Detection service seeks to resolve back-end revenue losses by searching for third-party eligibility where none was previously identified. This is an important distinction; Nemadji staff typically begin work after all other internal and external eligibility detection efforts have ended.

One of the more commonly recoverable revenue items for last-in-line eligibility detection lies in Medicare and Medicaid. As Medicare has expanded to states under the ACA, more claims are being processed through this system, and Americans are finding themselves navigating its intricacies to pay for their care. The byzantine nature of Medicare claims processing makes it ripe for mistakes; Medicare is a complex system that utilizes third-party MACs to manage its billions of dollars in claims, and it requires intimate knowledge of the program to understand pitfalls and potential issues.

Don’t Give Up Too Soon

Eligibility verification is vital regardless of the age of service, and while Nemadji’s Eligibility Detection service addresses accounts from the time on service onward, it is our ability to recover revenue from accounts 60 days and older that really sets us apart.

Further, Nemadji’s Eligibility Detection service doesn’t begin and end with basic eligibility. We explore eligibility as far as state regulations allow, incorporating analytics-based discovery tools and software, as well as manual support for providers to recover their earned revenue that would long ago have been abandoned by staff or by other vendors. We also have great success overturning timely filing denials for our clients.

Conclusion: Let The Right Payors Pay

More money is coming out of patients’ pockets than ever before, creating a delicate balance for healthcare providers. No hospital wants its reputation diminished by prolonged wrangling with patients over eligibility or coverage. An efficient eligibility detection process can not only be a boon for your bottom line, it can also be an asset in achieving patient satisfaction. This is why many are choosing to outsource this aspect of the revenue cycle.

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