Comprehensive
Insurance
Investigation

Almost everything you need to know about comprehensive insurance investigation - your path to fewer denials and more revenue.

Section 1

What is Comprehensive Insurance Investigation?

Preventable denials plague healthcare organizations. Billions of dollars per year are lost because providers weren’t aware that a patient had insurance. Comprehensive Insurance Investigation takes aim at both challenges. Through thorough insurance investigation, you can reduce preventable denials and increase your confidence that you are billing third parties for all covered appointments, whether insurance information was disclosed or not.

With Comprehensive Insurance Investigation, you correct, gather and record as much insurance information possible. In doing this, you cover as many bases possible as efficiently as you can.

In a lot of scenarios, getting a patient’s entire insurance profile isn’t a seamless process. It utilizes many people in different phases. There is a disjointed flow of information where things can get lost or skipped.

With Comprehensive Insurance Investigation, the process starts with the first patient interaction. That could be at scheduling or registration, depending on the nature of the visit. The process follows six phase flow that is designed to seamlessly gather as much information possible. The result is a complete and accurate view of a patient’s insurance picture. The benefits include denials reduction, increased revenue, and less frustration.

6 Phases of Comprehensive Insurance Investigation

 1. VERIFY KNOWN COVERAGE

The verification phase may be the most obvious and commonly practiced step in the process. You never know when a patient’s demographic information has changed or was inaccurately recorded until you check. Insurance information changes all the time. You can never be sure you have good information unless you verify what you have is accurate.

 

2. IDENTIFY AND CORRECT INSURANCE INFORMATION

Verification can be thought of as a pass or fail situation. Either the information you have is accurate or it isn’t.  

In some cases, the reason verification failed is obvious. The change needed is easy to identify. That tends to be the exception to the rule. Usually, more research is required.

In the identify phase, you are not only identifying an error, but the solution, too. For example, you find you spelled a patient’s name, “John Deo,” and the insurance provider spelled it “John Doe.” You have identified both the error and the solution.

 

 3. DISCOVER HIDDEN OR MISSED INSURANCE  INFORMATION

Missed insurance coverage is a hidden problem. You won’t even know if you have missed a patient’s active coverage unless you look. Healthcare organizations lose millions of dollars every year by mistakenly classifying patients as self-pay or as not having secondary coverage.

The most effective way to discover missed insurance is by running eligibility checks with your payers. If you do this for every patient, you will discover missed prime, secondary, and tertiary coverage.

It may seem like overkill to check for coverage for every patient (self-pay or not!) with several payers. However, organizations conducting discovery find the effort provides a significant return on investment and so they are more than happy to perform the checks.

 

 4. GATHER ADDITIONAL INSURANCE INFORMATION

There have been some recent shifts in healthcare. Healthcare organizations are beginning to understand the importance of price transparency. The patient financial experience is getting more attention than ever before. With the rise of high deductible plans, patients are sharing more of the cost for their care.

It isn’t enough to know that a patient has insurance. It is also important to know all the details like co-pay and deductibles as soon as possible. This information is almost always available in the payer portal. Part of Comprehensive Insurance Investigation includes capturing this information during verification. This gives you a more complete view of the patient’s insurance picture.

 

 5. ORGANIZE INFORMATION TO EASY-TO-USE WORK   QUEUES

Now that you’ve done all the diligence you can, you must organize the information in a way that makes it easy to use.

We are in an industry filled with work-lists, which is unlikely to change anytime soon. Many work-lists are related, though. Meaning, they could be part of a bigger list that matches the entire workflow.

In the case of comprehensive insurance discovery, you might think of one work-list to add discovered insurance. Another to make corrections. Yet another to submit the claim, and another again to allocate the payment to the encounter.

Comprehensive insurance investigation is as much about efficiency as it is insight. Work-lists are necessary to handle the information coming out of investigation. Those work-lists should be designed to match workflows.

 

6. UPDATE INFORMATION

Once the work-lists are generated, it’s time to use them. One way to make sure the information is properly leveraged is automation. If you can automate the information update process, you won’t need to rely as heavily on staff or worry that the process isn’t happening consistently. Not only will automation ensure compliance, but your staff will be happier, too.

By taking a closer look at root causes and best practices, you can start your journey to comprehensive insurance investigation.

Section 2

Proactive Denials Prevention

Why denials prevention?

Denials are often considered an inevitable cost of doing business. Entire teams are devoted to working denials, costing time and money. Meanwhile, each day that passes between the date of service and the submission of a clean claim reduces your chances of being paid. The healthcare industry is starting to embrace the idea that “an ounce of prevention is worth a pound of cure” when it comes to denials. Organizations are turning more attention to proactively preventing denials at the source. As a result, more claims are accepted on the first pass, downstream work is mitigated, and patient revenue increases.

When you consider why claims are denied, you can begin to see that the most common causes can be prevented with diligence and technology:

  • 28% of denied claims are due to registration errors or inactive policies
  • 15% of denied claims are due to the service not being covered
  • 5.8% of denied claims are due to a missing prior-authorization
  • 1.1% of denied claims are due to inaccurate coordination of benefits

The reality facing revenue cycle leaders is that up to 20% of submitted claims will initially be denied [2]. Only two-thirds of those denials will be recoverable. Due to time and resource constraints, only 65% of the recoverable denials will be re-worked [3]. It’s easy to see that once a claim is denied, the chances of reimbursement are seriously diminished.

But, hope comes in the form of denials prevention. Up to 90% of all denials are preventable [2]. If you can imagine the benefit of having 90% less denials to work- 90% less claims in danger of not being paid, the case for denials prevention is difficult to ignore.

Once the decision to focus on denials prevention is made several questions need to be answered:

 

 What steps can I take to prevent denials?

 

How can I prevent denials with the lowest impact on current operations?

 

Will the results justify the effort?

 

If I decide to make the change, what steps can I take to make sure the change sticks and the effort is a success?

 

 

In this guide, we will take a closer look at all these questions. We will highlight the steps you can take to prevent denials and the benefits that come from those steps.

Finally, we will offer suggestions to give you the best chance of success.

Denials prevention is one of two pillars of comprehensive insurance discovery. When combined with maximizing reimbursement potential through insurance discovery, you will have a powerful set of tools and strategies helping you reduce denials, increase revenue, and save considerable time doing so!

Section 3

Why Insurance Discovery

Health system leaders indicate that addressing bad-debt is a top priority. Incorrectly identifying covered patients as self-pay and not identifying secondary and tertiary coverages are two contributing factors to bad-debt.

Many organizations are turning to insurance discovery to stop the leakage caused by not having a complete picture of each patient’s insurance.

 

Missed insurance leads to bad-debt

Our experience tells us that anywhere from 1 and 7 percent of all accounts written off as uncompensated care come from patients with coverage that had not been identified. Designating insured patients as self-pay is one of the leading ways hospitals lose money.

There are a variety of reasons health systems miss a patient’s commercial or federal coverage. For example, emergency visits are unscheduled and urgent. Health systems don’t have much opportunity to collect, verify, and correct information before treatment occurs.

Some patients aren’t even aware they have coverage. Certain demographic or disability status automatically qualifies individuals for federal coverage, but recipients aren’t aware they meet the criteria. Additionally, parents of nearly half of the children covered by federal programs have no idea their child is covered [4].

Retroactive Medicaid is another area where health systems can bill a third-party but aren’t aware. Medicaid coverage is effective retroactively for a period of time before the patient applied. That means a truly self-pay encounter could be billed to Medicaid if the patient received coverage after treatment occurred. Up to 8 percent of a health system’s uncompensated care could be avoided by identifying retroactive Medicaid and most health systems try to identify those opportunities. Those efforts are often manual, so health systems sometimes miss the opportunity to bill during the window of opportunity.

A patient that changes insurance providers can also be misclassified as self-pay. Systems and procedures to identify a change in coverage aren’t always fool-proof. Many rely on someone remembering to ask the patient if anything has changed while others consist of the patient simply signing a form indicating nothing has changed. In either case, if the patient isn’t asked or doesn’t disclose the change, the claim will be denied due to no policy found. Without knowing the new policy information, the health system has little recourse for getting paid.

The underinsured and bad-debt

The Affordable Care Act (ACA) led to an historic number of insured individuals. The number of uninsured individuals decreased from about 44 million in 2013 to below 27 million in 2017[5]. While ACA did wonders in reducing the number of uninsured individuals, the number of individuals in high deductible plans skyrocketed.

Patients with a balance after insurance rose from 8 percent in 2012 to 12.2 percent in 2017[5]. As a result, in 2016, uncompensated care started to increase for the first time in years [3]. Bad-debt fared no better. Medicare bad-debt alone, meaning moneys not paid for copays and coinsurance, increased by 17% from 2012 to 2016 [3].

The trends are concerning, but health systems are not helpless in reacting to them. A significant amount of balance after insurance revenue can be captured by identifying secondary and tertiary coverage that was missed.

The bad-debt conundrum

In June of 2018, HealthLeaders published an article stating that health system executives are dealing with rising levels of bad-debt[7]. Behind that trend is the fact that for the first time in years, uncompensated care is on the rise[8].

There is no getting around the fact that the self-pay and self-pay after insurance challenges are directly related to rising bad-debt. Health systems need to adapt to the changing environment by taking every course of action they can to recoup every possible dollar.

Insurance discovery

In the face of these challenges, new strategies are imperative. The right insurance discovery strategy will equip you to meet these challenges by proactively identifying missed Medicaid, Medicare, and commercial coverage either before a patient presents or soon after discharge.

By discovering payer responsibility early, health systems avoid the significant costs of labor, billing, and third-party collections. You also increase your likelihood of being reimbursed for services that require prior-authorization when you identify the payer before the patient presents. Finally, the sooner you discover coverage, the more you reduce the concern of missing timely-filing deadlines.

With the right discovery approach, you can identify retroactive Medicaid by periodically searching for coverage on all outstanding accounts.

Insurance discovery is a pillar of the comprehensive insurance investigation process because in today’s environment, health systems cannot afford to miss one available dollar. The only way to make sure you’re recognizing every opportunity to bill is with a robust insurance discovery process.

 

Jump to Finding Missed Coverage

Section 4

Expanded Insurance Verification

Reduce errors and denials by verifying, validating, and correcting

Why it matters

42% of denial write-offs are due to missing or inaccurate information like a patient’s name, member ID, social security number, or relationship to guarantor[9].  Many claims are denied because coverage was terminated before the patient received care, and more yet because a deductible hadn’t been met[10].

Claims denials cost hospitals $262 billion a year, which signifies money those hospitals were owed and will never receive [11]. For denied claims that were reversed, it costs $25[12] on average to re-work a claim and about $118 to appeal one[13].

Just looking at the numbers tells us that preventing denials will provide more revenue and reduce costs, creating a boon to bottom-line revenue. There are few efforts you can make that will increase revenue and decrease cost. You usually choose which will have the biggest impact to the bottom-line. Denials prevention is one of the few efforts that grow revenue while shrinking costs.

What’s more, only about two-thirds of denials are recoverable, but almost 90% of them are preventable[14].

The most common reasons claims are denied include[15]:

  • Incorrect patient identifier information
  • Coverage terminated
  • Prior-authorization required
  • Services excluded or non-covered
  • Coordination of benefits

If we take insurance verification beyond just verifying coverage and expand it to verifying coverage, validating information, and correcting discrepancies, the impact on denials prevention can be huge.

Expanded Insurance Verification Best-Practices/ Workflow

Verification is one of the first steps in financial clearance. If done comprehensively, verification isn’t limited to verifying that the stated coverage exists. It will also give you what you need to identify and correct errors that could lead to a denial. For every discrepancy you identify and correct, you are saving your organization $25 to $118 dollars and helping prevent denial write-offs.

The following workflow will ensure you’re doing all you can to prevent registration related denials.

3 Steps To Prevent Registration Denials

1. INSURANCE INFORMATION ACCURACY

It is just as easy to prevent denials due to demographic errors as denials due to insurance information errors. Most payers make policy details available through their portal, so the information is readily available.

Again, the most important thing is making sure the information you have matches exactly with the payer. Learning the information matches or doesn’t match isn’t enough. For any information that doesn’t match, you need to collect what the payer has and update the information you have to match.

Pieces of information to validate are:

• Policy number, member ID, or subscriber number

• Subscriber’s name

• Subscriber’s relationship

 

2. DEMOGRAPHIC ACCURACY 

Denials or rejections because of missing or inaccurate demographic information are one of the easiest to prevent.
A comprehensive demographic validation will ensure the following pieces of information are included in the claim and match the payer’s records:

• Patient’s first and last name

• Date of birth

• Social Security Number

It is most important that name, date of birth, and social security number match. Ensuring you have the right address and telephone number will help considerably if you need to follow up with the patient for payments.

For any information that doesn’t match, you need to collect the information the payer has and use that to update your own records.

 

3. ADDITIONAL INSURANCE 

Additional information is available on most payer portals that will aid in preventing denials and estimating the patient’s share of financial responsibility. For example, you can determine if a prior-authorization is needed and ascertain deductible and copay amounts.

When to verify

There are varied recommendations on when to verify insurance. Most advice seems to err on the side of caution and recommends verifying benefits at several different points in the patient journey including:

  1. Scheduling
  2. Pre-registration
  3. Point of service
  4. Day after service

While these recommendations certainly are thorough, there is a lot of repeat effort. If you are paying transaction fees each time you verify benefits, this method drives those costs up. If you are manually verifying benefits, you are paying for repeated efforts.

Insurance coverage rarely changes during a calendar month, so we recommend verifying benefits at a point where the information is most likely to cover the date of service. For example, if a procedure is scheduled six months out, verifying benefits at that time is not idea as it is more possible the information will change before service. If service is scheduled for May and benefits are verified in May prior to service or very shortly after, you can be confident that you have relevant information.  This also allows you to identify issues while leaving enough time to update your records before the claim drops.

The challenge with a one-time verification is not having the reassurance that if one person fails to follow the procedure to verify benefits, someone else will. To overcome that challenge, we recommend verification be automated and scheduled. If automated verification is scheduled based on the date of service, there is no concern that verification will be missed.

Technology to support verification

The reality in today’s healthcare environment is that the time demands are growing faster than headcount. If an organization is to perform at maximum potential, they need to leverage available automation technology to supplement the efforts of their staff.

We already discussed the fact that automating verification reduces the need to perform several queries for one appointment. Another benefit is time savings. If your team spends less time verifying benefits, they have more time to devote to things that technology isn’t as appropriate for- like delivering an amazing patient experience.

Section 5

Identifying Missed Insurance

Growing revenue with insurance discovery

Why it matters

We previously outlined the fact that the rising rates of self-pay and self-pay-after-insurance are causing uncompensated care rates to climb in tandem. A significant amount of self-pay or self-pay-after-insurance revenue is written off to bad-debt every year. 

Our own experience has proven that a robust insurance discovery process, one in which commercial and federal payers are searched to identify missed coverage, can create significant gains in patient revenue.  That is, some of these patients classified as self-pay or underinsured may in fact have a payer source that was missed.  In a 173-bed hospital we work with, insurance discovery efforts net around $17 million per year- 3% of their total patient revenue. When you take discovery efforts beyond the self-pay population and look for secondary and tertiary coverage, you can cut bad-debt by up to 10% [16]! 

Insurance discovery matters because it yields the lowest hanging fruit in reducing bad-debt and growing revenue. The money is sitting on the table. You only need to find it. One revenue cycle director we spoke with said,

“Insurance discovery is like Christmas every day. We did everything possible to capture every patient’s insurance information, so were convinced the discovery results would decrease…but they didn’t. Every time we got a file, we could bill third-parties thousands of dollars we thought were self-pay.” 

Insurance Discovery Best-Practices/ Workflow

1. Be proactive

Some organizations concentrate discovery efforts on accounts with outstanding balances. For example, if an organization writes accounts off to bad-debt or sends them to bad-debt collections at 120 days outstanding, they might conduct discovery on any accounts in the 90-day outstanding bucket. This is an effective approach in ensuring you don’t sacrifice revenue that could be billed or invest in erroneous collection efforts, but it puts you at a disadvantage. You risk losing accounts to timely-filing and don’t have the opportunity to get prior-authorization where needed. Time and money have been invested in trying to collect on the account before it aged, and the longer an account remains unsettled, the less likely reimbursement becomes.

In the ideal scenario, discovery is conducted before the patient presents for service. This provides ample time to associate any found coverage and identify prior-authorization needs. We recommend conducting discovery soon after an appointment has been scheduled and before the date of service.

Not all encounters present the opportunity for discovery before a patient presents. For example, emergency visits are unscheduled, as are walk-ins. We recommend conducting discovery as soon after unscheduled events as possible.

If discovery is done proactively, several advantages are revealed, including:

 

  • Information can be updated, and claims processed before timely-filing deadlines.
  • Prior-authorization needs can be identified with enough time left to make requests.
  • Costly downstream collection efforts can be avoided.

 

2.  Include all patients in insurance discovery

We already mentioned the fact that you can experience up to a 10% reduction in bad-debt by simply identifying secondary and tertiary coverage. You can identify those additional resources by Including insured patients in discovery efforts.

Including insured patients in discovery also helps reduce coordination of benefit denials as you identify all resources available to a patient.

To get a complete view of all third-party billing opportunities, it is important you include all patients when searching for additional resources in your efforts.

 

3.   Include retroactive Medicaid identification

In most states, when a patient qualifies for Medicaid, they are eligible for retroactive coverage. Healthcare delivered before the patient qualified for Medicaid may be eligible for reimbursement.  In other cases, while the application is pending, there may be a lag between the time that the patient was seen and when coverage is confirmed.

Identifying retroactive Medicaid as early as possible opens a whole new revenue stream.

To find retroactive Medicaid as early as possible, you should be checking for eligibility for patients who don’t already have Medicaid coverage that you are aware of accounts receivable. This is another area where discovery after discharge is extremely valuable.

 

4.   Connect directly with payers

There are a host of services offering the ability to search for missed insurance, but many of them rely on proprietary databases or clearinghouses for their information. Our research has shown that while these services do return results, those results include both false positives and false negatives. False positives create unnecessary work because your team goes through the process of generating, submitting, and following up on claims destined for denial. False negatives result in missed billing opportunities and revenue.

To get results of the highest quality, you must connect directly to the payer. The payer is the single source of truth and holds the most up-to-date information.

Working directly with payers requires more effort, but the quality of information returned is well worth the effort.

 

5.   Automate

Insurance discovery involves systematically searching for coverage with payers. It is a time-consuming and repetitive process. Doing so manually is unfeasible for even the smallest of facilities. Even if it were possible, the amount of time and investment required would make the investment difficult to justify.

Insurance discovery needs to be an automated process if it is to provide a decent return on investment.

Even with automation, most organizations find that the time required to build, monitor, and manage the processes is difficult to find. For that reason, most outsource their discovery efforts to a trusted vendor.

By partnering with a vendor, they can manage the process. You need only worry about leveraging the results. The right vendor will manage the changing rules, technologies, and ongoing maintenance, making discovery a mostly hands-off process. Return on investment typically exceeds 500%, making the partnership a revenue generator, rather than a cost.

 

6.   Prioritize

There comes a point where insurance discovery falls victim to the laws of diminishing return. When the process is automated or outsourced, it is easy to think checking every available payer is the smart choice.

The fact is, every discovery query represents a cost whether it is automated in-house, or a vendor is doing it for you. You want to make sure you are getting an adequate return on investment per payer to reach the full potential of insurance discovery.

We recommend limited your discovery efforts to somewhere between three and six of the top payers in your payer mix. Doing so will optimize your return-on-investment potential.

When business leaders think about increasing revenue, strategies often involve tactics that increase overhead. For example, many healthcare executives would say to increase revenue they must enhance the patient experience and quality of care in order to attract more patients. There is nothing wrong with that approach. Increased volume will certainly increase revenue, but it comes at a cost. Increasing patient volume also means increasing all the overhead associated with serving those patients and collecting payments.

Insurance discovery is one of the few ways you can increase revenue without a substantial increase in overhead. In fact, in some ways, insurance discovery reduces overhead by preventing a lot of patient billing and collection work.

As leaders grapple with rising bad-debt and uncompensated care, insurance discovery is one of the most potent tools in the toolbox. It should be considered a necessary component of any healthy revenue cycle.

 

Section 6

Preparing for Success with Comprehensive Insurance Investigation

All too often, technology projects or purchases are viewed as a “magic pill.” The belief is that implementing and running the solution should result in immediate success. The truth is, 31% of the time, new projects fail to meet their stated objectives [17]. For any initiative to be successful, you need to prepare for success. Successfully implementing comprehensive insurance investigation is no different.

Our first foray in to insurance investigation started with an engagement focusing only on insurance discovery. The process quickly became a wild success. We took a close look at what made them so successful and identified a few important factors.

Designating a Team

There was a young lady at this site dedicated to researching high-dollar, self-pay accounts to see if the patient had any coverage they’d missed. She was passionate about finding the hospital money. When insurance discovery began delivering results, she was assigned the task of making sure the new information turned in to cash. Having the tool behind her gave her a huge boost in productivity and the results she could deliver.

As they added payers, more revenue flowed in. They formed a team of people dedicated to working the results from insurance discovery.

Imbed the project in to your culture

The insurance discovery solution and the hard work of the team turned in to a significant revenue stream for this hospital. On average, reimbursements as a results of insurance discovery represented 3% of their total patient revenue.

It was important to them that everyone working for them understood the importance of incorporating this work in to their processes. To make it part of the operating culture, all new hires are first assigned to the insurance discovery team while they learn the EHR.

To this day, insurance discovery continues to be a successful pillar of their revenue capture strategy.

Communication

This organization was different from many we’ve worked with in that inter-departmental communication was very strong for this project. Members of the project team made a point to visit all campuses regularly. They shared the results of insurance discovery and helped them understand how they could contribute. As a result, the entire organization understood the process, its importance, and their role in making it a success.

Executive Buy-In

A project of this scale needed continuous support, both operationally and financially. They understood that when the CFO reviewed financial statements and budgets, the benefit of insurance discovery would be lumped in with patient revenue while the cost would be a separate line item. They knew that the future of the project relied on executive leadership’s understanding of what they were getting for their investment.

They met with the CFO regularly to highlight the incoming revenue and efficiency gained through the insurance discovery project. These presentations became something the CFO looked forward to. He was always excited to get to them showing how many millions of dollars insurance discovery earned them. Because of these meetings, the insurance discovery project has always had the full support of the CFO. Budget allocation is never a concern, and when the insurance discovery team needs additional resources, they get it.

Why projects like Comprehensive Insurance Investigation fail

There are several reasons projects fail. Some of the leading causes for failure include [18] :

 

1. Lack of resources

A project simply cannot succeed without dedicated resources. All to often, new initiatives like comprehensive insurance investigation are implemented and staffed by “fill-ins.” That is, people who chip in on the project around their other tasks.

It is natural for people to have multiple responsibilities, but a project with no line-level employees equipped for and accountable to its success is sure to fail.

 

2. Poor project handling

Every project or initiative needs a competent leader. With software, solution, or service purchases, it is not uncommon to think the purchase replaces the need for a champion. The result is lack of communication and direction. When the purchase fails to deliver the desired results, the solution is blamed. The truth is, the solution might have worked fine but there was no one to guide the team to best uses.

 

3. Lack of stakeholder buy-in

It is reported that 33% of projects fail due to lack of interest from top management [18].

When projects need budget or resources, top management typically decides if the project gets what it needs. Top management also sets the tone for the organization. If they are not excited about a project, it won’t get the resources it needs to succeed. It also won’t get the display of support needed to achieve buy-in from the entire organization.

Preparing for Success with Comprehensive Insurance Investigation

How to make your comprehensive insurance investigation a success

 

1.  Designate a project sponsor

The project sponsor should be a direct beneficiary of the project’s results and have influence over the people responsible for the tasks that will make the project successful.

For comprehensive insurance investigation, a good project sponsor would have a title like Revenue Cycle Director, Patient Access Director, or some other managerial position with responsibility in denials prevention and reimbursements.

It is the project sponsor’s job to designate roles and responsibilities, keep the project on track, communicate the wins, and redirect activity because of the losses.

They will also communicate with top leadership- reaching as high as possible. We experienced the best results presenting project status and results directly to the CFO. In some large organizations, that may not be feasible, but you should reach as high in to your organization as possible. Your discussions with leadership should build excitement. That excitement will lead to resource allocation and support in championing the project throughout the entire organization.

 

2.  Map the flow of information

It is important to know how the information derived from comprehensive insurance discovery will flow through your revenue cycle. In most cases, a daily file results file will be made available for someone to pick-up. Once that occurs, records with errors and/or additional insurance information need to be updated. New insurance needs to be allocated to the eligible encounters. Authorizations need obtained and claims need to be generated and submitted.  Submitted claims require follow-up, denials need managed, and payments need posted.

Mapping the flow of information will prove invaluable in the next step- forming a task force.

 

3. Form a task force

After you’ve identified the flow of information, identify the departments that will handle the information. The form a comprehensive insurance discovery task force comprised of specific people in each department handling the information.

Work together with your task force to outline how they will work with one another. How hand-offs can be made seamlessly, what each of them needs from the other in order to have the greatest chance of success.

What you now have is a cross-functional insurance investigation team. The benefit of a cross-functional team is that they tend to be high-performing. Regular meetings will drive that performance.

 

4.  Meet with your task-force regularly

To convert your cross-functional team in to a high-performing cross-functional team, the entire team needs to meet at regular intervals.

In the beginning phases of implementing comprehensive insurance discovery, this team should meet weekly at a minimum. As the team starts to sync and the insurance investigation engine starts humming, those intervals can be spaced out accordingly.

During these meetings, you should discuss:

  1. The wins! It’s important to celebrate the wins early and often. This will keep your team energized and committed.
  2. Where the project should be at the time of the meeting.
  3. Where the project is at the time of the meeting.
  4. Root causes of any variance between where the project should be and where it is.
  5. Open discussion about opportunities for individual team members to do things differently that will help the overall team.
  6. Recalibration of goals for the next period.
  7. Plan of action for the next period with specific and individual actions (So that each team member knows exactly what is expected of them).

Having this open forum will keep your team excited and focused on the important items that will support their continued success.

 

5. Share the success

One of the more excited aspects of our first insurance discovery engagement was what they called the “road show.” During a road show, members of the insurance discovery team would visit other locations on campus to talk about what they were doing. They would explain the process and the results.

Sharing the success served two purposes.  Members of the team had the opportunity to do a little bragging, which only enhanced their engagement in the project. The recipients of the road shows got to share in their excitement, which led to organization-wide buy-in for insurance discovery.

 

6. Get Executive Support

Again, when leadership reviews a balance sheet and notices a 3% increase in net patient revenue, they aren’t going to make the connection when they’re reviewing budgets and see a line item for insurance investigation or an increase in labor expense in the revenue cycle. They won’t make that connection unless it is pointed out to them.

It is important they know why insurance investigation is valuable before the project even begins. They should know that it will open brand new revenue streams while reducing costs associated with managing denials. It should be made clear that comprehensive insurance investigation is a strong tool when dealing with shrinking margins due to an increase in patient financial responsibility.

They should also get frequent updates on the progress and benefits of the effort. They should be informed of the outcomes and action items from the weekly meetings. That will reassure them that the project is being well managed and producing good results.

The most important portion of the meeting is where you get to say, “Comprehensive insurance investigation helped prevent 1,000 denials, which saved us $25,000 in rework. Furthermore, we found billable coverage on 200 encounters that had not been identified. That provided an additional $70,000 in net patient revenue!” While these numbers are made up, you get the point. If they understand the cost savings and revenue growth associated with the effort, they will be avid fans.

With executive buy-in, comprehensive insurance discovery will continue to get the financing and resources it needs to reduce denials and grow revenue indefinitely.

 

7. Never finish the project

With something like comprehensive insurance investigation, the project is never “done.” Implementation can be called complete, but the process will need to be continuously measured and managed to get the most out of it.

Decide what your definition of success is and measure it relentlessly. Continue to have meetings to discuss the results and areas for improvement. Your task force might grow and your core stakeholders might move on, but as long as comprehensive insurance discovery remains embedded in your culture, it will continue to bare the fruit of less denials and more revenue.

Sources

[1] https://blog.databoundhealthcare.com/blog/creating-a-proactive-revenue-cycle
[2] https://www.advisory.com/research/revenue-cycle-advancement-center/at-the-margins/2014/12/denials-management
[3] https://www.beckershospitalreview.com/finance/the-best-denial-recovery-strategy-prevention
[4]  https://www.beckershospitalreview.com/finance/finding-and-fixing-leaks-in-your-hospital-s-revenue-cycle.html
[5] https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
[6] https://www.healthcarefinancenews.com/news/hospital-bad-debt-rises-tandem-growing-share-patient-financial-responsibility
[7] https://www.healthleadersmedia.com/finance/industry-wide-issue-bad-debt-over-10m-one-third-hospitals
[8] https://www.healthleadersmedia.com/finance/uninsured-patients-drive-most-self-pay-revenue-hospitals
[9] https://www.insynchcs.com/blog/infographic-the-5-most-common-reasons-for-medical-billing-denials
[10] https://acrbulletin.org/departments/radlaw/165-claim-denials
[11] https://www.modernhealthcare.com/article/20170627/NEWS/170629905/insurance-claim-denials-cost-hospitals-262-billion-annually
[12] https://www.mgma.com/resources/revenue-cycle/you-might-be-losing-thousands-of-dollars-per-month
[13] https://www.beckershospitalreview.com/finance/denial-rework-costs-providers-roughly-118-per-claim-4-takeaways.html
[14] https://www.advisory.com/research/revenue-cycle-advancement-center/at-the-margins/2014/12/denials-management
[15] https://www.verywellhealth.com/insurance-claims-denial-2317138
[16] https://revcycleintelligence.com/news/finding-medicaid-eligibility-cuts-hospital-bad-debt-by-10
[17] https://www.askspoke.com/blog/it/reasons-for-it-project-failure/
[18] https://blog.taskque.com/why-projects-fail/

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