Transcript the PowerPoint

Intake, Benefits &
Authorizations
Overview
Prepared and Presented by
Mae Regalado
and
Linda Hagen
Objectives
1.
Discuss the nature and importance of effective patient
intake and front-desk procedures at the time of patient
check-in.
2. Review benefit authorization processes and their
relevance to billing.
3. Review patient check-out and co-insurance collections.
Intake Process
• A functional billing system begins with having an efficient
and effective patient intake process, as well as with
tracking each patient's information throughout each
encounter.
• This ensures that patients receive the services they need
and that they're billed appropriately for those services.
• Evaluating a provider’s entire process, from patient
check-in through treatment services and follow-up, is
extremely important to establishing and maintaining an
efficient system.
Intake: Basic Principles
• The following basic principles should help as you assess
your own intake and charge-capture process.
– A smooth patient check-in is essential to meeting the needs of
each patient in an orderly fashion.
– Front-desk staff members need to initiate a patient charge sheet
(which also may be called an inpatient encounter form or
outpatient encounter form) for each patient.
– The patient's insurance policy and policy number should be
listed on the form.
– If the patient has health insurance. A copy of the patient charge
sheet is then attached to each patient's medical record.
– The patient charge sheet should follow each patient through his
or her office visit.
Patient Check-out and Billing
• Before the patient leaves the office, staff uses
the patient charge sheet to gather any additional
information needed and make any arrangements
needed.
• This could include processing a referral to a
specialist or even making preparations for
admitting the patient to a hospital.
Billing Process
•
•
•
•
•
In order for the billing process to be
effective, providers must pay attention to:
Insurance Coverage
Benefits Verification
Eligibility Verification
Authorization Verification
Co-pay collection
Eligibility Verification
• It is more important than ever to check on the insurance
eligibility of every patient.
• According to industry sources, 75% of all healthcare
claim denials are because a patient is not eligible for
services billed to the insurer by the provider. Often, a
patient would be ineligible for benefits because his or her
policy has been terminated or modified.
• Patients switch plans more frequently than they used to,
and they are bearing more of the cost of healthcare.
More on Eligibility Verification
• Over the course of treatment, as patient balances tend to
grow due to higher co-pays and/or coinsurance, it is
critical to focus on reducing those balances
• There are several ways to check eligibility, but the oldfashioned method of going through health-plan rosters
line by line is labor-intensive, and the lists are often
inaccurate.
• Calling the plan on the phone usually takes too much
time, unless a voice response system is available.
More on Eligibility
• Many health plans allow practices to check eligibility
online, and some enable them to do that with swipecard terminals.
• Insurers such as United Healthcare offer “real-time
claims adjudication,” so practices can instantly find out
what the patient owes out-of-pocket before he/she
leaves the office.
• Providers dramatically reduce accounts receivable and
increase revenue, by significantly reducing the impact of
ineligibility, and increasing the number of "clean" claims
that are sent to health plans insurers (a clean claim is
complete, accurate and for patients who are eligible for
benefits).
More on Eligibility
Why Eligibility Verification Matters…
• Unfortunately, eligibility verification is one of the most
neglected elements in the billing process.
• In the absence of proper eligibility and benefit verification
countless downstream problems are created: delayed
payments, rework, decreased patient satisfaction,
increased errors, and nonpayment.
Authorizations
• Health care precertification, also known as prior
authorization, is an essential component of
comprehensive utilization review.
• A Prior Authorization or Authorization is a process of
reviewing certain medical, surgical and behavioral health
services to ensure medical necessity and
appropriateness of care prior to services being rendered.
• Most health plans require prior authorization for specific
services.
More on Authorizations
• Health plan insurers typically provide outlined
authorization requirements and guidelines.
• If the services meet the required criteria, health plans
will assign a prior authorization number and send the
provider/practice a letter that includes the number.
• Be sure to include the prior authorization number with
your claim for proper reimbursement.
More on Authorizations
• If a provider wants to render additional services beyond
what is covered by the initial authorization, the provider
must notify the health plan and typically a new
authorization number will be issued.
• A new authorization would also be needed if the provider
wants to make any changes to the patient treatment,
such as extending dates of service.
• Be sure to understand exclusions and limitations.
Some services that do not require prior authorization
may have limitations in coverage or be excluded under
the health plan program.
More on Authorizations
• Prior authorization requirements are subject to
change as a result of annual benefit
modifications and/or during annual prior
authorization requirement reviews.
• Most health plans’ prior authorization
requirements are reviewed annually to evaluate
medical and behavioral health care trends and
better control health care costs for the
government.
Benefits: Co-pay Collections
• Keen attention to co-pay collections has become more
critical as employers and insurance companies pass
more of the cost of care on to patients.
• Patients now face higher deductibles, larger co-pays,
and more shared expense for procedures and testing.
• It is a good time to look at how your organization handles
patient finances and implement strategies to address
these changing trends.
• This is especially true for providers accustomed to
treating the indigent.
More on Benefits
• Staff should obtain a patient’s co-pay when checking
his/her eligibility (Note: The amount on the insurance
card is not always correct).
• Practices should also try to collect the co-pay before
the patient leaves. Otherwise, you could spend more on
collecting the co-pay than you receive.
• Co-pays can add up: If your average patient has a $20
co-pay and you see 30 patients a day, that’s $600;
plenty of no-frills plans now require much higher co-pay
and deductible levels.
• Also, check the patient’s balance before he heads for
the door.
Pulling it all Together
• Even with the right software, patient billing is a challenge
requiring many vital steps and a coordinated effort by
medical office staff and physicians.
• Someone in the practice needs to oversee the process
(intake, benefits and authorizations), keep track of
reports, and make sure that billing statements and
collection letters are mailed on time.
• When the details of the process get the right attention,
your office and its patients can expect accurate billing,
which is an important component of a well-run office and
healthy patient relations.
Thank You! Questions?
Mae Regalado and Linda Hagen
Senior Consultants
888-898-3280
www.ahpnet.com
www.behavioralhealthtoday.com