5 Percent of Your Self-Pay Patients Likely Have Medicare Coverage

Ensuring correct patient demographic and insurance coverage information during emergency outpatient encounters is essential to the health of a hospital’s reimbursement and bottom-line finances. 

 However, during medical emergencies, paperwork is the last priority; the focus is — and should be — the patient. Gaps in demographic and insurance information are commonplace. Patients are often mislabeled as self-pay despite the presence of billable (but not provided) insurance coverage. ZOLL Data Systems’ internal reporting across all client sites validates this common revenue cycle challenge.  

  • Approximately 20 to 40 percent of presumed self-pay patients have insurance coverage —commercial, governmental, or a combination.
  • Half of these have government coverage — Medicare, Medicaid, or are dual-eligible beneficiaries.
  • Conservatively, 5 percent of patients assumed to be self-pay, have Medicare coverage but did not supply the information. This may sound like a small percentage of cases. However, an organization’s ability to discover coverage and bill Medicare can result in a significant (and compliant) revenue boost. 

Making the Case for Insurance Discovery and Verification in Self-Pay

Many facilities rely on manual, labor-intensive insurance verification processes that lack the ability to yield complete, accurate results. Indeed, these traditional workflows no longer suffice as organizations must find and recoup every dollar of earned healthcare revenue in the wake of COVID-19 volume and revenue losses. 

New technologies with the ability to search multiple data sources and provide a patient’s social security number, date of birth, and other critical information have become paramount. Advanced insurance discovery technology is especially helpful in the COVID-19 environment with telehealth adoption and a higher occurrence of incomplete demographic and insurance information, due to lost or changing employment. 

In fact, these tools can reap a significant insurance discovery rate in patients initially assumed to be self-pay, opening an easier pathway to reimbursement. Having tools to help with patient information verification and insurance discovery in self-pay populations is more important than ever in order to: 

  • Capture the right demographic and insurance data at the front end of the billing process to resolve issues that result in lost revenue. 
  • Verify complete, accurate patient demographics and insurance coverage in real time. 
  • Streamline the search process so that a single query can quickly identify and verify coverage, delivering accurate, billable information. 
  • Find coverage for self-pay patients and convert to Medicare, Medicaid, or commercial insurance rather than write off the loss. 

To effectively employ AR optimization technology, begin by using a demographic verification product to run name, address, date of birth, and social security number to ensure billing the right person the first time. Then conduct insurance discovery to avoid downstream issues such as rejected claims, missed filing deadlines, and costly collection efforts. Effective insurance discovery also reduces the volume of claims categorized incorrectly as self-pay. In fact, our data shows that 5 percent of self-pay patients are eligible for Medicare, even though they may not yet be enrolled. 

For those who have Medicare coverage, Social Security Numbers (SSN) and Healthcare Insurance Claim Numbers (HICN) have been replaced by Medicare Beneficiary Identifiers (MBI). Without an MBI, claims billed to Medicare will not be paid, and collecting the patient’s MBI at the time of service is not always easy. Many patients may not have their new Medicare card available, and recalling the MBI is more difficult than providing their familiar SSN. Pairing a batch MBI tool with Insurance Discovery can facilitate the lookup process through an automated, multi-database search capability. 

How to Ensure Effective Use of Pre-billing Technology Solutions 

Pre-billing technology builds on the information collected by ED, outpatient, and other providers. That is why collecting accurate, complete information is critical to effective use of pre-billing technology. Here are three best practices to consider: 

  • When possible, collect information from the patient/family member prior to discharge from the ED or ambulatory care facility. Request copies of driver’s license and insurance cards, and ensure that required paperwork is completed. 
  • Capture comprehensive information. Achieving optimal results from insurance verification requires more than name, address, and DOB. Get a telephone number, insurance information, an email address, and SSN. Past addresses can be a source of valuable information.
  • If an old Medicare HICN or SSN is provided, it’s possible to cross reference and identify the MBI. Until the MBI is entered into the database, retain the HICN. If the patient returns without their MBI card, access to old data serves as a link to the MBI. Consider using an MBI batch lookup tool. 

Integrating insurance discovery, verification, and MBI lookup tools into pre-billing expedites cash flow and uncovers billable Medicare coverage for patients that would otherwise be presumed to be self-pay. If 5 percent of write-offs are converted to Medicare-billable claims, the impact on the bottom line can be substantial. Identifying all possible revenue opportunities at the front end of the billing process and submitting a clean claim reduces costs related to manual verification, claim rejections, and returned mail. Efficiency gains help to reallocate resources to more critical activities. Especially during this era of instability, lean operations and the ability to convert self-pay cases to Medicare gives providers a competitive advantage. 

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