The Real Life Pitfalls of Failing to Check Eligibility By Karen J Kuhn Revenue Cycle Management Consultant

Everyone knows checking eligibility is important. If we know it’s important, why do we still have so many denials and rejects for eligibility?

Because it’s NOT Black and White!

Broad Objectives Scanning cards Choosing the Correct Carrier Entering Insurance on Patient Registration Checking Eligibility through CPS Tracking eligibility problems Adding carriers to CPS eligibility

Train Your Patients o Bring your identification o Bring your insurance cards o Bring your copay money Starting with pre or mini-registration Appointment reminder calls Front desk Nurses All lines of business, same message

Train Your Front Staff Verify insurance prior to reminder call Verbal check of patient info – “What is your address please”? Not “Are you at 123 Sesame St.”? Scan ID and ins cards every visit Domino Effect…Incorrect demographics > failed insurance filing > with incorrect address > time & postage lost > incorrect phone number > ineffective collection calls All of this results in lost income.

Managing Financial Scans VisDoc – Many benefits Paper clip – scanning attachment, core CPS product Scan to EMR – last resort – financial scans in a health chart = loss

Scanning Medicare Information Scan red/white/blue card Replacement plan card, both sides Supplemental plan card, both sides

Scanning Medicaid Information Scan the state card Scan any additional HMO cards

Scanning Private Insurance Private Insurances scan the front and back of the card The back of the card gives not only addresses but billing instructions: The back of this card tells you that if you are billing SNF or Hospice claims, they go to your local BCBS plan with prefix YLS. If billing medical, claims go to UHC.

Examples of Cards The back of this card says “File to the Local BCBS Plan” This card, same BCBS symbols, send claims to a specific address in Chicago, IL

So much information on one card! Notice the Prefix, ID and Suffix Refer to slide 15 PCP referral required Pcp must refer to all specialties. Referrals to In Network providers or auth required for out of network referral. For this pt, only in network because… No out of network benefits

Looks like UHC, it’s not Busy and confusing

This is a specialty card, no medical coverage A very common error is when a patient gets updated insurance, they bring in the card, front desk sees same carrier and doesn’t check ID/Group changes.

Decoding Insurance IDs BCBS must have a prefix SOME insurances must have a suffix It’s not Black and White. You might need it for elig! PrefixID NumberSuffix YBC

Know your Population State Medicaid programs vary, managed care, specialty carriers Medicare replacement plans per county Know your Blues Common private carriers in the area Know credentialing, update front desk Look for new carriers coming into your geographic area

Insurance Naming Conventions Choose a method of naming Create a policy for Carrier Naming Major payer/Line of Business Spell words, do not abbreviate Minimize the number of selections BUT don’t minimize too far Remember, it’s not Black and White !

Choosing the Correct Carrier by Address Often an unfamiliar carrier can be found by the PO Box on the back of the card (that is scanned for reference!) Also great if you can only read part of the address on the card Just the number, brings back that number in any part of the address

Choosing the Correct Carrier by Name If your carrier file is clean, insurances can be searched by the first few letters of the name or if a specialty, the specialty itself Use % as a wildcard for searching parts of names

Clean Carrier Example Medicare NGS Medicare Noridian Medicare Wrap Medicaid FQHC Medicaid FFS Medicaid Wrap United Healthcare Medicare Advantage United Healthcare Medicaid HMO United Healthcare Commercial Dental United Healthcare Dental DentaQuest Behavioral United Healthcare Behavioral

Clean Common Carriers Messy carriers are easily cleaned up – management decision Train the naming convention to all Allow only one or two well-trained staff to enter insurance carriers Enter new insurances with correct Allocation set and Finance Class Communication process for adding insurance carriers

Order of Insurances Order of payers in registration is how they pull to a ticket Medicaid always pays last, may not be listed last Active insurances should be in order of payment and checked as active Specialty insurances should not be active in registration but handled in a case

Order of Wrap Insurances Medicare Advantage Plan Medicaid or Commercial Carrier Medicare Wrap Plan Medicaid Advantage Plan Medicaid Wrap Plan

Entering Insurance Information No dashes or spaces – know your plans there are exceptions Policy Group If registering Medicare as secondary, use drop down to choose reason

Insurance Subscriber Insurances require subscriber on the Insurance tab Additional information to be gathered: o Subscriber name o Social security number o Date of birth o Patient’s relationship to subscriber MCR & MCD Subscriber is same as the patient

The Birthday Rule Mom and dad both have insurance on the children. Little Bobby comes in for his wellness check, dad hands over two insurance cards. Which is primary? Gather your subscriber info on each plan. Mom’s DOB is April 4 and Dad’s DOB is September 29. Mom’s insurance is primary. The first birthday in a CALENDAR year determines primary insurance carrier.

Checking Eligibility from Schedule For the entire schedule it runs as today’s date Primary Insurances only Prints on a report Populates into patient registration record

Checking Eligibility from Schedule For Individual selected patient Primary insurance Populates into patient registration record

Checking Eligibility from Patient Registration Date of Service is SO important here!!!

Eligibility error messages Facility and must be entered for eligibility to run.

Scratch the Surface of Eligibility Do not rely on radio buttons! Please open the eligibility, double click the notes box

Reading CPS Eligibility Medicare

Reading CPS Eligibility Medicaid

Tracking Eligibility Issues Audit registration information including Insurance and Eligibility Create Owners that reflect Eligibility Rejects o CO 140 Name/Number mismatch o CO 22 Pt has primary ins o CO 24 Pt covered by HMO o CO 26 Prior to coverage o CO 27 After coverage termed o CO 31 Pt can’t be identified as our insured o Carriers use codes differently, make sure you know what your carriers are saying

Tracking Eligibility Issues Talk to your billing staff, they know what is rejecting, what are they correcting “all the time” Train, retrain Consider a “Registrar” position o Pt with confusing insurance cards o Pt updating income needing calculations o New registrations o Updating a family of accounts

Found Money Any time you can bill a self pay/SFS ticket to a payer Search Medicaid elig on self pay/SFS patients, including OB and newborns Process to communicate new ins or income from front desk back to billing to capture older DOS While in a pt account, Financial Tab, Calculate button

Adding Eligibility for Insurances Eligibility goes through the same clearinghouses as claims Visualutions’ primary clearinghouses: o Claim Remedi o Practice Insight o Availity o CEDI – through GE We may be able to help with others as well

Most Common Errors Not running eligibility Not reading eligibility Leaving off the alpha prefix on BCBS Tricare, using the wrong ID Name doesn’t match insurance Date of Birth doesn’t match insurance 0 v. O – that’s a zero, not a letter O Details matter, double check your work!

Summary Scan cards, they are invaluable Check Eligibility 100% of the time Audit registrations for correct entry Track eligibility issues If a carrier is a significant part of your business, and not checked electronically, try having it added through the clearinghouse.

Additional Resources Adding insurances to Eligibility o Joely Hendrix (281) x 4231 Additional CPS Eligibility PowerPoint Additional Availity Clearinghouse Eligibility Info

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