Leveraging multiple data streams to accelerate reimbursement and enable agile operations

Consider this scenario: A child enters the hospital emergency department with a broken collar bone, sustained while at play. Upon admittance, the child’s parent fills out forms for the child and provides demographic and insurance information — the “source of truth.” Later, someone in the hospital’s patient financial services department manually enters the information provided by the parent in preparation for billing but finds no active insurance coverage. She visits the insurance company website, phones the insurance company, goes back to the hospital admissions department and contacts the child’s parent — all in an effort to locate accurate coverage information. This long, drawn-out process is not uncommon, and sometimes there’s a person (or several people) whose job consists entirely of tracking down billable insurance.
 
That form, that “source of truth” that the patient (or oftentimes, the patient’s parent or spouse) completes at the time of service isn’t always available. In fact, when an EMS agency responds to a medical emergency, many times, they rely on the destination hospital to provide critical patient information to them later, after the patient is admitted. It’s a big issue for non-hospital providers: Because they don’t have that first-person documentation, they need to do even more legwork to identify accurate information and billable coverage than hospitals do.

The pre-billing process during which the hospital, EMS agency or physicians group financially clears the patient shouldn’t require one or more full-time billing specialists submitting and re-submitting claims, chasing down billable coverage for 60-90 days. Yet in the U.S. healthcare system, so many people representing so many interests touch patient data that there are multiple points at which essential data can be corrupted or deleted. Re-keying errors are entirely too common. HIPAA limits what can be shared, and providers send bills to past insurers or the wrong insurer altogether.

Here are three problems providers commonly experience:

1. Patients entering hospitals via the ED: Key pieces of information — driver’s license, current insurance, Medicare card — are never at their fingertips. Add to that challenge the data entry component (some estimates claim that 25-40% of demographic errors are due to typing errors). Data problems are only discovered when the claim is kicked back.
2. Patients receiving treatment from EMS: Information collected at time of transport is the basis for billing. Often, patients treated by EMS don’t have essential documents on their person or a financial representative with them during transport to the ED. Tracking down additional information is afterthought for most crews. Lacking complete information, EMS billers try to use whatever they have immediately or experience delays while they wait for the hospital to share their fact sheet, enter the information manually into the EMS billing system (introducing another opportunity for errors and omissions) and submit the claim. This scenario also places the EMS agency one step removed from the “source of truth” and forces reliance on the hospital for providing accurate information.
3. Billing via Third-Party Biller: Billing for EMS or hospital, third-party billing companies add another layer and are one more step removed from the “source of truth.” Not always operating in the same state as providers and with no relationship to the patient or with the hospital, billing companies typically receive data electronically as electronic data interchange (EDI). Once the data is imported into their system, they go through the same verification steps as providers do. Typically, they try to bill within five days of the date of treatment to fulfill the contract stipulations. The practice of prioritizing speed before accuracy has unintended consequences. Bills may be sent to the wrong place or directly to the patient to see what happens. A high proportion of claims are rejected or returned in the mail as undeliverable.

If billers could capture the right data at the front end of their process, it would solve a lot of issues. If the system worked optimally, it would be easy to enter the patient information once and facilitate output of insurance so that claims could be billed immediately.

Insurance Discovery Slashes Effort and Turbo-Charges the Billing Process

Fortunately, there is insurance discovery software capable of making that happen. Finding and verifying patient demographics and insurance coverage in real time is not only possible; it’s a game changer. Technology streamlines the labor-intensive and costly search process to the point where a single query can identify and verify coverage, delivering accurate, billable information in as little as 15 seconds.

It’s not just the time and effort saved that makes the technology so valuable. Billing the claim to the right party the first time translates into many benefits. The entire revenue cycle is more efficient, fewer claims are rejected and there’s even a cost savings on postage with less returned mail. Importantly, accurate billing also contributes to higher patient satisfaction and protects the provider’s reputation. When patients are billed for services that insurance should have paid, it’s more than just bad PR; it taints the entire care experience from the patient’s perspective. If the patient ignores the bill, it may be sent to collections, making a bad situation so much worse. Meanwhile, 90-120 days have passed, and the biller may have to abandon the claim because it’s now past the insurer’s timely filing limit.

Of tantamount importance is sending the bill to the right party the first time. Once you’ve got the details right, you can step on the gas and accelerate the claims process.

Start by using a demographic verification product to run name, address and DOB so that you bill the right person. Next, conduct insurance discovery to head off any problems downstream. It’s an affordable step, it works and it pays big dividends. No more rejected claims. No more missed filing deadlines. Effective insurance discovery will also reduce the number of claims lumped inaccurately into the self-pay category.

Pre-Billing Technology Builds on the Information You Collect

There are three essential steps you can take to ensure success using pre-billing technology solutions:

• Capture as much information directly from the patient or family member prior to the patient leaving your agency’s care or hospital discharge. Obtain copies of the patient’s driver’s license, insurance cards and make sure they fill out any paperwork completely. Regardless of whether services are provided by EMS, hospital or some other facility, the same best practices apply.
• More information is better. No insurance verification technology will work if the only information provided is name, address and DOB. A limited data set is likely to yield limited results. Be sure to always get a telephone number, insurance information (even if it’s outdated, it’s better than none), an email address, if possible, and the patient’s SSN if they’re willing to provide it. Even past addresses provide additional information to work with.
• If an old Medicare HICN or SSN is provided, it’s possible to cross-reference and identify the patient’s Medicare Beneficiary Identifier (MBI). Until the MBI is in your database, don’t retire the HICN or delete it from the system. If the patient returns without their MBI card, having their old data in your system will act as a bridge to their new identifier.

Integrating insurance discovery into pre-billing speeds up cash flow. Billing the right party the first time puts money into your coffers sooner and slashes the cost of staff and expenses related to claim denials and re-submissions, returned mail and manual verification. You may well find that you gain so much in efficiency that you can reallocate some resources to more critical activities.

That kind of flexibility is welcome, especially in the unstable environment resulting from the COVID-19 pandemic. Lean operations give providers a competitive advantage. Remote work is hardly possible if the entire process is paper-based, but the transition to working from home is much more seamless when technology enables productivity from any location. Streamlining and automating critical phases of the billing process helps providers become more agile and positions them to respond quickly to changes to “business as usual.” While we can foresee a time when the current crisis has passed, events inside and outside the healthcare industry will continue to impact how and by whom patient claims are paid. Harnessing the power of available technology-based solutions will ensure that we’re prepared, come what may.

Additional resources:

​To learn more from Zoll Data Systems about improving billing and collections during the COVID-19 pandemic, click here to register for the MGMA webinar, "Positively Shifting Your Payer Mix." The 60-minute webinar, which is eligible for ACMPE, ACHE, CME, CPE (live only) and CEU credit, is Aug. 27 at 1 p.m. ET and will be made available as a recording.