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Stop Relying on the Patient for Accurate and Timely Payer Information

We have all heard the famous but unattributable quote, "Insanity is doing the same thing over and over again and expecting different results."

Yet, when it comes to billing and revenue cycle management services, as an industry, we have been doing the same things for the last thirty years and expecting the same — if not better — results. Patient responsibility has grown by more than 29%, and yet many of us are still using the same processes and billing systems, while lamenting our shrinking revenue.  

We blame the payers, and while I certainly am not able to absolve them of responsibility, as RCM professionals, we too are part of the problem.

We expect patients to understand and navigate a complex healthcare financial environment that we, as experts, struggle to understand ourselves.

A UnitedHealthcare Consumer Sentiment Survey1 showed that only 9% of Americans surveyed “showed an understanding” of four basic health insurance terms — health plan premium, health plan deductible, out-of-pocket maximum, and co-insurance. Yet, we imagine that these same consumers understand the importance of giving us accurate and detailed payer information as well as their full demographic profile.  

The reality is that patients do not understand and often fail to provide the correct information.   Patient demographic information tends to include errors or omissions nearly 55% of the time.  What is more, once misinformation has entered the claims process, patients do not want to spend time contacting insurers or providers to resolve claims issues. They simply want the system to work. 

That means expecting a statement that accurately captures insurance coverage and patient financial responsibility. Patients genuinely believe that by giving us a little bit of information, they have done their part. Unfortunately, they do not have the knowledge to understand how missing or incorrect information impacts the entire claim process and may result in an increase in their patient responsibility. 

Information Provided by the Patient Is Not the “Gospel Truth.”

A study published in JAMA Network Open2 revealed that up to 81% of patients lie to their doctors about how often they exercise, how much they eat, and other behaviors to avoid being judged. What’s more, the same study found that patients reported lying when they did not understand what their doctor or their doctor’s staff was asking.

Let us think about that for a moment: patients don’t just lie when they feel their lack of healthy habits will be judged. They also lie when they don’t understand. We know that patients struggle to understand their own health insurance. Sometimes a patient may not intend to give us misinformation; they have simply forgotten that they have a new insurance card or that their driver's license still lists an old address. 

Retooling the Patient Demographic Verification Process Will Increase Patient Satisfaction 

More than ever before, patients are becoming informed healthcare consumers, especially when their financial stake continues to grow. As patients engage in managing their cost of care, they need a clear understanding of what they owe for services. Billers need to discover all active billable coverage for this to occur. 

Rather than relying on the patient to provide accurate and complete information, I suggest providers simplify their intake process to focus on verifying the patient’s identity and obtaining basic information. Review the patient’s identification and ask them to verify that you have their full and correct name, date of birth, address, social security number, and where appropriate, their MBI number. Beyond that, take the insurance card, but before relying on this information as the gospel truth and entering it downstream, verify it! Utilize a demographic verification and insurance discovery process prior to presenting the information to your billing team. 

Leverage Advanced Technology to Verify Patient Demographic Information and Discover Billable Coverage. 

Providers can deliver on patient expectations by leveraging advanced technology such as demographic verification and insurance discovery to boost billing performance. Improving operational efficiencies and claims processing time can be done in real time, and the process can increase patient satisfaction, too. Process the demographic verification and insurance discovery during the encounter, while the patient is. Review what has been found together and leverage that information for a more productive financial discussion before discharge or checkout. 

Providers who deploy best-in-class technology can expect to recoup 29% more billable coverage on average, increase clean claim rates, and have an easier time engaging the patient in the process. It’s time we stopped relying on old, inefficient practices and started taking full advantage of the technology and tools available to us. 

This article is a collaborative effort with ZOLL Data Systems.

 

About the Author: 

Few people have the ability to move an organization from where it is to where it wants to be. Juli has been able to do just that and has been a driving force for growth throughout her career. With a knack for discerning what customers value, she’s been instrumental in finding solutions that foster success and create strong ROI. Juli greatly expanded market share and profitability for a medical coding company by embracing innovation in response to challenges related to the shift from fee for service to value. In other roles, she grew an indirect sales channel by 535%, led year-over-year growth for an emergency medicine start-up and helped triple the membership of a non-profit. 

Today, Juli serves as Director of Strategic Partnerships for ZOLL® Data Systems. By harnessing the unique data mining and predictive analytics capabilities of the ZOLL AR Boost™ solution, she develops partnerships that enable health systems and providers to realize more revenue, decrease bad debt and increase operational efficiencies.

Juli is a nationally known speaker on emergency medicine coding and reimbursement issues. She has served on committees for the American College of Emergency Physicians (ACEP), the Emergency Department Practice Management Association (EDPMA), and the Urgent Care Association (UCA). She is currently a member of the Board of Directors of EDPMA and is one of a select few non-physician members of the ACEP Coding and Nomenclature Committee.

 

"UnitedHealth survey: Most Americans don't understand basic health plan terms,” Healthcare Dive website, https://bit.ly/3oyJCXL

”Prevalence of and Factors Associated With Patient Nondisclosure of Medically Relevant Information to Clinicians,” JAMA Network Open website,  https://bit.ly/2HKw4r6

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