Eligibility Verification & Prior Authorization to Reduce Denials & Payment Delays

The importance of accuracy in patient registration, insurance eligibility verification, and securing of prior authorization cannot be understated in today’s environment of escalating denials and payment delays, with recent surveys including one by Change Healthcare indicating that nearly a quarter of denials stem from errors or inaccuracies in patient registration and eligibility verification. As patients continue to shoulder a greater share of healthcare costs, accurately communicating financial responsibilities and payment options is also of critical importance, as the complexity of co-pays, deductibles, co-insurance, and self-pay increases. Organizations must consider methods for increasing accuracy in eligibility verification and prior authorization in order to reduce denials and payment delays, but also to improve overall patient satisfaction in a context where patients understand their financial responsibilities and are given opportunities to pay in a way that is attainable.

Registration: Confirmation of Benefits & Eligibility

In order to ensure swift reimbursement from payers, provider registration and eligibility teams work to quickly ascertain eligibility and levels of coverage and payment responsibilities for patients, in order to provide a clear picture of the financial responsibilities associated with care. Accuracy as well as completeness of information in the collection of patient insurance data is critical, and reducing errors of paramount importance. Communicating with patients to ensure the correct insurance details as well as any supplemental or co-insurance information is collected is a first but perhaps most important step in ultimately smoothing the patient journey.

Successfully Securing Prior-Authorization for Care

Changes across the payer landscape has increased the difficulty in securing prior-authorization for care, with payers using disparate criteria and processes for submitting and tracking prior-authorization requests. While providers strive for higher levels of automation through using online systems for data submission, payers frequently require burdensome and time consuming follow-up phone calls and in some cases, the need to fax information back and forth in order to obtain approval. As hospital staffing continues to exert a challenge on registration teams, thorough but rapid training and oversight of new staff is also required to ensure prior-authorization is secured.

Patient Financial Responsibilities: Co-Pays, Deductibles & Self-Pay

As health plans have increased in complexity, deductibles for many have risen, and co-insurance or supplemental insurance plans have gained additional traction, it can be difficult for patients and caregivers to understand at-a-glance what their financial responsibilities will be. Provider staff are not only tasked with determining payment responsibilities, but also collecting co-pays and self-payments from patients who may or may not be expecting the amount of payment required.

Reducing Denials & Payment Delays

Ultimately, fast and accurate eligibility and prior-authorization will lead to a reduction in denials as well as timely reimbursement from payers, improving the financial performance of the organization and saving time on the back end through reduced management of denials. Surveys also link a smooth financial transaction with overall rate of patient satisfaction, underscoring the need smooth financial pathways to care.

Interested in this topic?

If registration, eligibility and prior-authorization are a concern for your organization, consider joining us at the Patient Financial Services meeting taking place live online this October 11 & 13, where breakout discussions will provide industry executives an opportunity to dive deep into these issues. Leaders from organizations including UF Health Jacksonville, Tift Regional Medical Center, Mayo Clinic and Massachusetts General Hospital will lead interactive discussions on these topics, giving attendees the chance to benchmark and share best practices.

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