Patient Eligibility Verification 10-Part Interview: Vishal Gandhi of ClinicSpectrum, Booth #301 at HBMA

After the resounding success of our recent 10-Part medical practice workflow Interview with Vishal Gandhi of ClinicSpectrum, well, why not do it again?!

However, even I, a glutton for workflow punishment, couldn’t do *another* 10-part interview about workflow with the same, undeniably smart and multi-faceted person, such as Vishal! So I let V. pick the topic: Patient Insurance Eligibility Verification. Back when I was CMIO for an ambulatory EHR vendor for over a decade, we dealt with eligibility verification, but boy has it gotten complicated since then! So I learned so much during this, intentionally in-the-weeds, interview with Mr. Gandhi.

I’m sure Vishal would appreciate me adding, he and his company, ClinicSpectrum, is located in booth #301 at the Healthcare Billing Management Association Conference in September 14-16 in Las Vegas. 🙂

By the way, I’ve left the words and phrases IN ALL CAPS exactly I as got them from Vishal. 🙂

  1. The 2014 Consumer Health IT Summit is happening September 14 (same day as the HBMA Conference) in Washington DC. It’s about empowering patients with their digital data and technology. So my first question is: From a patient engagement perspective and the patient’s point-of-view what are benefits of a well-run medical office patient insurance workflow?
  2. What are typical limitations of EHR/Practice Management systems? And how does ClinicSpectrum eliminate them?
  3. What kinds of information about a patient’s eligibility verification are NOT available through software technology interfaces?
  4. What are some Do’s and Don’ts when calling to inquire about covered vs. un-covered procedures?
  5. Once you know a patient’s eligible benefits (high deductible, non-covered, max caps, etc.) what are appropriate action plans?
  6. What are typical percentages of denials due to eligibility issues? How much can these percentages be reduced through a more proactive approach?
  7. Tell me about your medical office Micro Finance Company analogy. What are some workflow management implications?
  8. As deductibles go up, how can medical practice begin to manage their patients’ “viability” of paying their portions of the bill?
  9. What’s is best and most cost effective manner to follow up on balances through a “soft” collection method?
  10. Where do you see Eligibility/Benefit Verification going years from now? How will it fit into larger population health and care coordination landscape?

Into the weeds!

The 2014 Consumer Health IT Summit is happening September 14 (same day as the HBMA Conference) in Washington DC. It’s about empowering patients with their digital data and technology. So my first question is: From a patient engagement perspective and the patient’s point-of-view what are benefits of a well-run medical office patient insurance workflow?

A well-run medical office patient insurance workflow results in a lower cost of care by health plan and a lower cost for patient. Plus, patients don’t like to be surprised with lot of medical bills unpaid by their health plans! So, a clear idea of health plan benefits, covered and uncovered tests/procedures in outpatient and inpatient set up is of utmost necessity. Excellent patient insurance workflow contributes to a healthy relationship among the patient, their clinical needs and heath insurance coverage in today’s changing healthcare space due to ACA and ACO.

What are typical limitations of EHR/Practice Management systems? And how does ClinicSpectrum eliminate them?

Any efficient workflow engine has balanced combination of automation and human element which follows certain protocols and processes. EHR/PM is definitely an essential element of workflow in a medical practice; however it does not substitute the requirement of human element or man power in effective practice management.

First and foremost common limitation of EHR/PM systems is eligibility verification. While some software offers online Verification of Benefits, more often than not the information does not have enough detail about various procedure codes covered, amount met-to date, coinsurance, and specific benefit information, leading to higher chance of denials after services have been rendered.

ClinicSpectrum’s eligibility verification team overcomes limitations of EHR/PM by making calls to Insurance Representatives for detailed Verification of Benefits. Each call lasts over 30 mins and results into answers to several questions related to patient’s health plan as per customized templates provided by the medical group.

The second human element comprises of filing scanned/faxed documents into EHR system. It is essential for provider to have necessary clinical information at the time of service including all tests and procedures done within office and outside. ClinicSpectrum’s indexing team focuses on filing these documents into patients’ chart with proper identification, date and description. All documents scanned/faxed are indexed in a timely and cost effective manner. Total cost savings in indexing documents with ClinicSpectrum’s team is up to 40% compared to practice’s own staff.

The third human element is requirement of preparing or studying gap in patient’s care plan or risk management. This requires clinician or medical assistants to review active problems, allergies, treatments and procedures and preparing personalized prevention plan. It is difficult for physicians to review all this information even though most EHR’s have some sort of decision support. ClinicSpectrum’s clinical team helps providers in Population Management, Care Plan oversight and Recalls for required Preventive Tests/Procedures.

Last and most crucial human element is tracking/follow up of claims submitted to insurance companies. Even though most EHR/PM systems submit claims to Insurance companies’ electronically, it is a known fact that 18 to 24% of claims are unpaid or require some sort of tracking and follow up. Claim Tracking through EHR/PM system is limited in its capabilities and same is the case with ONLINE or INSURANCE companies’ website. It is essential to make a phone call to the insurance company and question their reason for denial or non-payment of a claim beyond 30 days. ClinicSpectrum’s Accounts Receivable Follow up team specializes in chasing insurance companies’ for outstanding claims until they are paid.

What kinds of information about a patient’s eligibility verification are NOT available through software technology interfaces?

Eligibility verification is a crucial aspect of running a business whether you work for a billing company or physician’s practice. With an additional 30 million uninsured Americans now receiving healthcare coverage under the Affordable Care Act, verifying procedure benefits, prior authorizations, referral requirements if applicable, and covered and non-covered conditions for certain procedures is imperative. Without such verification, you will likely experience high levels of insurance denials and lost revenue. ClinicSpectrum has been around the block and has helped numerous practices and companies get on the right track with eligibility which are not available through software technology interfaces. In fact, we frequently hear of many misconceptions when it comes to eligibility checking. While these may seem harmless, or “no-brainers,” these misconceptions can actually hurt your workflow and revenue. For example:

Misconception #1: Clearinghouses have all the answers.

Unfortunately, this just isn’t true. Clearinghouses certainly have an enormous amount of information and technical capabilities to gather some eligibility information, but it isn’t guaranteed to be accurate or thorough enough. To get speedy and accurate verification, you need live representation and phone calls from knowledgeable professionals.

Misconception #2: The EHR verification has all the information I need.

Anytime an EHR allows you to have Level 1 verification, it’s very basic. Too basic, in fact. You will likely not have access to specific diagnostic codes and procedures, precert authorizations, detailed answers to questions specific to each speciality. In fact, ClinicSpectrum can work off of the practice’s Verification of Benefits template to ask for specific details relevant to that procedure.

What are some Do’s and Don’ts when calling to inquire about covered vs. un-covered procedures?

It is essential to define covered vs. un-covered procedures. Almost all health plans have certain policy guidelines under which they would pay for claims from providers.

Health Insurance companies’ come out with variety of plans ranging from lower premiums to higher premiums. It is obvious that plans with lower premiums would have less coverage than those with higher premiums.
With Obamacare and Health Insurance Exchange, there is a minimum threshold of coverage, this enforces health plan to put lot of conditions for various treatments, procedures and hospitalizations.
It is essential for provider’s office to know covered and un-covered procedures in outpatient/inpatient and office setting. For example, several plans have office visits non-covered whereas well visit or physicals are covered benefits. This simply means that provider’s office would not get paid for office visit related to some sort of clinical conditions.

It is a common practice for health plans to provide coverage for hospitals owned diagnostic centers and no-coverage for free standing independent diagnostic/radiology centers. Insurance companies’ manage their coverage network or participation network as well. It may happen that provider’s office may have to locate IN NETWORK physicians/facilities for their patients in order for certain procedures.
Let’s take a look at some examples of questions required to be asked.

We need to define specific questions for coverage pertaining to your specialty of practice.

  • Asking for place of service for coverage
  • Asking for in network facilities for coverage of procedures
  • Medical Necessity / Clinical Requirements for coverage for procedures
  • Frequency limitations if any
  • Maximum allowed amount for particular procedure
  • Requirement of Authorization for Procedures
  • Deductible applicable for the procedure

Once you know a patient’s eligible benefits (high deductible, non-covered, max caps, etc.) what are appropriate action plans?

The first step to improving patient collections is to really understand the details of your patient’s insurance plan. This starts with doing an insurance eligibility check and verifying your patient’s plan details. We wrote about ways to streamline your insurance eligibility checks previously. Doing it right takes time, but with the right workflow automation solutions you can make sure that those working in your practice have the right insurance information. Once they have the right payment information, you’re much more likely to collect the payment from the patient while they’re standing in front of you at the office.

While collecting the patient payment from the patient while they’re in your office is ideal, there are dozens of reasons why this won’t happen. Some don’t have the money at the time. Some walk out before you can collect. Etc etc etc. How then do you engage the patient in the payment process once they’ve left your office? In the past, the best solution was to send out bill after bill through the US postal service or possibly call the patient directly. This is an extremely time consuming and costly process that can take 60 to 90 days to obtain results. Plus, it costs several hours of man power and postage.

In the electronic world we live in, the first thing you can do to improve your patient collection process is to implement an online patient payment portal. This online payment process increases patient collections dramatically. The next generation patient is so unfamiliar with writing checks and sending snail mail, that those payments often get delayed. However, by offering the online patient payment option, you remove this barrier to payment.

The other way to improve patient collections is to use an automated messaging and collection process. This approach uses a collection of text, secure text, email, secure email and even smart phone notifications and automated calls in order to ensure the patient knows about their bill and has the opportunity to pay the bill. Plus, these customized decision rules provide a much more seamless and consistent approach to collections.

What are typical percentages of denials due to eligibility issues? How much can these percentages be reduced through a more proactive approach?

Research reveals that 75 percent of all healthcare claim denials are due to the patient being ineligible for services billed to the insurer by the provider. Primary reasons why claims get denied are:

  • Patient’s demographic info doesn’t match health plan database
  • Patient has COB and health plan thinks they are secondary
  • Treatment/Procedure require prior authorization
  • Calendar year max reached for the benefits
  • Patient is not eligible at the time of service
  • Visits require referral from primary care provider
  • Visit applied to patient’s calendar year deductible
  • Provider is not member’s PCP
  • Services provided are not deemed medically necessary as per plan policy

Most of the above denials are due to in appropriate eligibility verification. It would be beneficial for practice to invest time in verification of benefit through a Live Insurance Representative. This would result into reduction of above denials. At least 50% of the amount noted can be reduces if a more proactive approach is taken by the staff.

Tell me about your medical office Micro Finance Company analogy. What are some workflow management implications?

Patient Responsibility for an office visit has increased from $10-15/visit to $30-$40/visit. Most of the employers are promoting “HRA/HSA” Plans. Health Insurance Plans marketed in healthcare market place has minimum deductible starting from $750.00 onwards.

Patient would have 3-4 visits/year to their primary care and/or specialist office. It is obvious that all of these visits would be applied to deductibles. Health Plan would reimburse money to providers’ offices only if the calendar year deductible is met. In a nutshell, the patient has to spend money for health insurance every month + out of pocket expenses per visit and medications.

It would be extremely difficult for several patients to spend this kind of money towards the cost of their care. It is even more difficult for providers to demand (or) force patients to pay such high costs up front.

Payment Plan/Micro Financing would be an essential element in the practice, just like Dentists or any other out of network surgeons or plastic surgeons. When your required money to take care of expenses is higher than your liquidity, people turn to financing.

Micro Finance is a field evolved out of financing smaller balances or loans. CareCredit is a perfect example of such a concept. Lots of patients may not qualify for THIRD PARTY finance companies. In this case, a practice may have to trust patients and hedge risk to finance their balances by making an appropriate payment plan.

It would be practically impossible for a practice to make payment plans without proper automation, tracking and reminder software such as AutoCollectSpectrum.

As deductibles go up, how can medical practice begin to manage their patients’ “viability” of paying their portions of the bill?

A practice needs to commit to certain workflow and policies in order to deal with patients’ portion of the bill. Let’s analyze the necessary steps below:

1) Practice needs to check detailed verification of benefit through a representative call and find out applicable deductible/copay/coinsurance and non-covered services for all tests/procedures applicable to the practice.

2) Practice should have a defined financial counselor who calls patients in advance and explains his/her benefits and his possible cost of first visit/second visit or tests/procedures beforehand. A trained financial counselor will not scare patienst but would collaborate with the patient and convey a strong message that “we will work with you”.

3) At the time of check-in, practice can collect CREDIT CARD or POST DATED CHECK on file towards an estimated patient responsibility portion. If patient is unable to pay this up front, he/she may be offered a payment plan.

4) Practice should have some kind of automation tool for engaging patients for their financial responsibility.

5) Practice may need some sort of automation tool to send invoice for the payment plan and auto processing of credit card towards payment plan or patient responsibility portion if authorized in advance by the patient.

6) Practice may need automation to reach out patients with high balances or unpaid balances through automated call, text, secure text and secure email.

With the above defined process, protocol and automation, practice can deal with patient portion of the bill much more effectively.

What’s is best and most cost effective manner to follow up on balances through a “soft” collection method.

As the name implies, a soft collection is a less severe form of collection. Practice will directly engage their staff to invoke urgency of outstanding balance through nicely drafted communications or letters. The practice will send increasingly urgent letters and make increasingly urgent phone calls to patients for balance collection.

In healthcare practice, secretarial hours required to do same job has increased by 30% over last 3 years due to increased audits, authorizations and medical necessity. It is increasingly difficult for practice to devote time towards soft collection utilizing its own team.

It is an industry trend to outsource collections to a THIRD PARTY COLLECTIONS agency, however most of these agencies use hard collection methods resulting in loss of active patients at times.

AUTOCOLLECTSPECTRUM automates the traditional collection methods of standard mail delivery and costly representative phone calls, to a more elaborate, seamless, cost eff­ective auto collection process. The automated collection methods with use of Technology Platform, Decisions Rules and Messaging such as Text, Secure Text, Email, Secure Email, Push notifications on Smart Phones and automated calls, allow seamless, consistent, proven results for balance collection.

Our proprietary collection method, delivers traditional communication means of letters and calls via an automated messaging channel. The debtor is relentlessly followed up for balance collection through decision rules customizable by the user. The date, time, hour and frequency of calls is auto set-up and notifications are delivered to the debtor simultaneously via our messaging methods.

BENEFITS OF AUTOCOLLECTSPECTRUM

By eliminating representative involvement and automating the process, the collector reduces his/her cost and increases the chances of outstanding collections. Following extensive auto collection efforts of balance recovery, if the debtor is non-responsive, he/she can be reported to Credit Bureaus automatically and/or sent to Legal Department for further legal proceedings.

Where do you see Eligibility/Benefit Verification going years from now? How will it fit into larger population health and care coordination landscape?

I strongly believe that Medical Policies for each plan will be programmed, and very soon front end adjudication engines will take over this function determining Procedure Level requirements and Medical Necessity (beforehand). This will lead into major efficiency in overall workflow management however this will also increase DEALING WITH HIGHER AND HIGHER patient responsibility. So practically speaking, medical offices would turn into Micro Finance Companies’ as the patients’ would never have the proper financing for care and Practices would end up making payment plans or find some outside Micro Finance Companies’ to fund the Patient Responsibilities’ portion.

That’s a wrap! I’d like to thank Vishal for sharing his passion for eligibility verification. Anyone who SPRINKLES EXPLANATIONS WITH ALL CAPS really cares. 🙂

Until next time… Vishal & Chuck!

7 thoughts on “Patient Eligibility Verification 10-Part Interview: Vishal Gandhi of ClinicSpectrum, Booth #301 at HBMA”

  1. One example to substantiate your first question. I met someone in my flight from Newark to Vegas. We started talking about healthcare and insurance problems. She mentioned an interesting story of her family member who was scheduled outpatient procedure in hospital. Everything went as per plan except pathology company sent a bill for $2300 for biopsy. Pathology company happened to be out of network with plan and patient didn’t have out of network benefits.

    1. Excellent point, Vishal…

      To date, when I thought of patient engagement, truth-be-told, I wouldn’t have thought of patient insurance, billing etc. However, there is so much potential for bad insurance workflow to create negative patient experience, that I now realize now how IMPORTANT it is to get patient health insurance and billing workflow right, ultimately, FOR patient engagement!

      I’m looking forward to monitoring the Healthcare Billing Management Association Conference tweets (#HBMA and #HBMA14) from Washington DC, where I’m attending the Consumer Health IT Summit (part of National Health IT Week).

      –Chuck

  2. Yup patient engagement is crucial as in Marketing Perspective “Customer engagement is necessary in everything a marketer does…branding to promotions to experience sharing”. This applies to healthcare as well. It is essential to engage patient for 360 degree workflow plan that revolves around patient’s well being and finally money in pockets of caregiver.

  3. Just now I spoke to one of the EDI vendor at HBMA 2014 show. Automation is leading to a detailed verification or CPT level verification in next coming years. However making a phone call to insurance rep is still an essential part of workflow.

  4. Interestingly one company in HBMA mentioned that they have more than 100+ professionals to follow up on outstanding patient balances and they continue to have more demand for the same. This indicates that patients balance is a reality. In order to deal with it, practice may need some automation and some human element.

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