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Insurance eligibility is getting even more complicated


Since the advent of the Affordable Care Act (ACA), there has been an increase in “narrow networks.” The Robert Wood Johnson Foundation defines narrow networks as those with less than 25% of the local healthcare providers in their network. Narrow networks are (at least partly) the unintended consequence of a critical objective of the ACA, which was to increase competition among insurers and thus (in theory) encourage them to offer low-cost health insurance products. 


Narrow networks proved to be one effective way to achieve this goal. Offering limited network plans gave insurers leverage to negotiate lower prices, either by selectively excluding high-cost providers or by promising high patient volumes to certain providers that may be willing to negotiate lower rates in return for the book.


As a result, narrow networks have exploded in volume in recent years. According to HealthAffairs, researchers at the University of Pennsylvania found significant variation in marketplace network breadth regarding physician participation as early as 2014. To wit, about 41 percent of 2014 plans had small or minimal networks, with fewer than 25% of area physicians participating. And the volume of such networks continues to rise.


Researchers in a study by the Employee Benefit Research Institute, “…anticipate the narrow network trend to accelerate as employers start to increase offerings of narrow network commercial plans to provide lower-cost options to their employees. We also expect increased ultra-narrow networks (<30% of hospitals and <15% of providers) to limit options even further to cut costs.”


But as well-intentioned (and perhaps effective) as they have been, narrow networks have incredibly complicated the medical billing process, often resulting in delayed or lost revenue for providers who don’t make the necessary adjustments to their medical billing practices. Here is what to watch out for to avoid medical billing problems with narrow networks.


Check eligibility for every patient 


Don’t assume that you are in-network with a patient just because you are contracted with the payer. It was once true that if you were contracted with a payer for a PPO, you were contracted for all of their patients covered under PPOs. With the rise of narrow networks, that is no longer the case. It would be best if you also considered checking eligibility for each visit on patients who are in-network, or at least periodically and especially for primary services like surgical procedures, imaging studies, etc.


Check patient benefits carefully


Even for patients that are generally covered and for whom you are contracted, they may not have the services you plan to deliver covered under their plan. Review coverage carefully to understand these nuances. If necessary, get a coverage determination.


Don’t lean too heavily electronic health records (EHR) software


EHR and EMR software will not always return information about patient eligibility. These software solutions are limited by the clearinghouse they use and their many connections with payers. You may well find that 10-20% of your patients cannot be checked, and you might even find a much larger number of patients, perhaps 30-40%, cannot be checked if you have patients with less common plans. These EMR systems will enable you to designate two clearinghouses or choose your clearinghouse. 


Make sure you check your payer mix to ensure that a sufficient percentage of your patients would be covered with the clearinghouses offered. If this is not the case, you may need to select a different software vendor or set up workarounds to check who is (and who is NOT) covered.


Utilize insurer websites


Create user accounts on the insurer websites for any payers you can’t check automatically or through EHR. You can use these as a backup to check patient eligibility.


Prepare in advance for patient visits


Get a copy of each patient’s insurance card before their visit, even if they must email or fax it to you. Determine whether authorization or referral is needed and what can be done before the patient visits. Check Medicare patients carefully. Most Medicare Advantage patients are unaware of the difference between their coverage and standard Medicare coverage, so they often just present with their Medicare card. They may be covered and not know it. 


In addition, many Medicaid HMOs (MCOs) have minimal networks, and patients often change plans reasonably frequently, so checking ahead of time increases your odds of collecting payment.


Train your reception staff


Create a checklist for your staff of what information to get from each patient. Write up very detailed instructions as a reference guide for them and quiz them on it. Also, make periodic checks to see that they are following the procedures. Keep a list of payer account ID’s/passwords handy so everyone on the front desk can access it. If the insurance card was not obtained before the visit, have your staff check eligibility while waiting.


Establish protocols for entering/editing payer profiles


Each EHR/EMR allows system users to enter and edit insurance profiles. The best practice would be to establish a single or small group of “super users” with full administrative access to the system. This is done by creating system access securities based on user groups or individual users. Key profiles to manage are patient, practice location(s), and insurance. With the surge in the narrow networks, insurance companies are finding new ways to carve out new divisions to keep their patient population and market share. 


In addition to different eligibility and benefits, each new division could have its insurance cards, payor addresses, and e-claim submission IDs. You could do everything right to ensure you have accurate eligibility, benefits, and insurance cards but cannot get the claim on file for processing and payment.


Monitor your results


Perhaps the most important thing to do to maintain your collections is monitor your results. All the above best practices will be in vain if your employees don’t follow them. And in some cases, you will run into problems beyond your control. In one recent Apache Health case, a client saw an unusually high percentage of Medicaid patients getting denied coverage due to ineligibility. As it turned out, this problem was caused by delays in updating the Medicaid website! Patients who had valid coverage, but may have changed plans within a 90-day window were still listed on their old (incorrect) goals. The problem was ultimately addressed by allowing a 90-day waiting period to collect each claim.


So, it is essential to set up analytics that will indicate your performance, such as the following:

  • Track the percentage of patient eligibility being checked on the front end (before patient visit)
  • Track all the denials on the back end, and quantify the results
  • Offer incentives to employees, such as bonuses or flex time, for consistency in following the written protocols.
  • If there are too many eligibility or coverage problems on the back end, provide a feedback loop from the medical billing team to the front desk to improve performance.


The enactment of the ACA has prompted an explosion of insurance products designed to be very cost-effective. And while this has resulted in some savings for patients, it has fractionalized and complicated the medical billing/payments process. And this phenomenon is not likely to slow down any time soon. So following the above guidelines, even if you need to spend a bit more time or money on staff hours, may be an excellent investment to ensure that your collections don’t suffer.

About Apache Health

Apache Health is a revenue cycle management (RCM) analytics, benchmarking, and auditing company. The founders of Apache formerly ran a large RCM company that was acquired by a private equity group in a rollup. Apache’s predictive analytics will benchmark billing performance and project exactly how much more revenue you should earn from your existing volume of patients.  Using many factors and a blend of artificial intelligence and specialty specific benchmarks, the model projects whether changing the billing process would improve collections for your particular mix of procedures and payers. Apache Health can help you evaluate whether to outsource the billing, determine which billing company to select to maximize performance, or track in-house billing performance improvement over time. For more information contact:


                  Sean McSweeney

                  Apache Health




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