The Importance of Insurance

Verification, Fee Transparency and

Bundling

Helen Lowenwirth, MBA, CASC

Administrator

East Side Endoscopy, LLC

East Side Endoscopy, LLC

� New York State Certified Ambulatory Surgery Center / AAAHC accredited

� Single Specialty Endoscopy (soon to be Dual)

� Affiliated with Mount Sinai Beth Israel

� Performed its first procedure in January 2010

� 10,000 Procedures Annually

� 23 owner physicians with independent practices serving the community

� 31 credentialed physicians performing procedures

� Medical Director is Dr. Brett Bernstein

� We have a very successful Charity Program and have performed over 600

free screening colonoscopies as part of the NYC Department of Health-

Community Cares Project

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The objectives of this presentation

� To explore what insurance verification really means and why it is so

important.

� How it can impact your operation, profitability and improve overall

operations.

� Recognize the increasing importance of fee transparency to patients.

� Talk a little about “bundling”.

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Verification Defined

The process of establishing truth, accuracy or the validity

Insurance Verification - Is the process of checking patient’s insurance coverage and benefits prior to date of service to insure

payment for services

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The Importance of Verification

� Why is verification so important ?

It is a critical component of revenue cycle management

� Claims will be paid if conditions for coverage are met…

� Insurance is inforce

� Premiums are paid

� The service is covered

� Deductibles have been met

� If it is medically necessary

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The Importance of Verification

• When should insurance be verified ?

� Every time the patient makes an appointment

� And Again on the Date of Service

� And Again for a follow up

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Gatekeepers

� Who Verifies ? The front office is your gatekeeper!

� Verification is the responsibility of the front office..

� Should be done at the time of scheduling

� Most verification is done on-line

� By the time your billing staff gets it ..it is too late

� Verification should be done AGAIN at the date of DOS

� Copy of card

� Address

� Other ID

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“ But I have insurance !” ….

� What do we Verify?

� Eligibility

� Coverage/Benefits

� Policy Limitations

� Financial Responsibility

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“ have you met your deductible” ….

What do we verify?

� Eligibility:

� If the coverage is in force (effective date)

� Premiums are paid

� Coverage:

� Is it a covered service (i.e. well exams, sick visits, maternity, etc. )

� Who is the Subscriber (Patient, Spouse)

� Primary vs. Secondary

� In Network vs Out of Network

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… they paid the last time I was here” ..

What do we learn when we Verify?

� Policy Limitations:

� Preventative services

� Contracted services

� Are pre-authorizations or pre-certifications required

� Pre-existing

� Patient’s Financial Responsibility:

� Co payments

� Co insurance

� Deductible

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Why are claims Denied

� Demographic Data

� DOB doesn’t match

� Subscriber # missing /invalid

� Group # missing or invalid

� Coverage terminated

� Eligibility

� Not eligible at DOS

� Pre-Authorization/ Precertification is (was) required

� Authorization timed out

� Non- Covered Services

� (some carriers require waivers for these so you can bill patient)

� Medical Necessary

� Reasonable, necessary for the diagnosis, injury or disease

� (do you have the documentation)

� Coordination of Benefits

� Primary vs Secondary

� Liability Carrier

� Worker comp/No fault

� Missing or Invalid Codes

� Timely Filing

� No Referral on file (from PCP)

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Life Cycle of an Endoscopy Procedure

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1. Patient makes appointment

Verify eligibility and benefits at physician

office

3. Physician recommends

procedure

4. Procedure

is scheduled/Instructions

5. Insurance cycle

6. Pre-call7. Appointment

Confirmation

8. DOS

9. Post- call /follow up

Billing Process

Make an appointment

Eligibility

Pre-registration Verification

Coverage

Pre-certificationVerify Pre-certification

Review with patient /Discuss

financial responsibility

DOS Rerun!

Verification Process

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1. Patient makes appointment

Verify eligibility and

Benefits

3. Needs referral /pre-certification

call patient /referring physicians

5. Obtain authorization

Verify authorization

Call patient to review financial

responsibility

DOS

Collect co-pay

9. Submit Claim

Fee Transparency

Providers are collecting a increasingly higher share of fees from

patients.

Driving more of a consumer oriented approach to obtaining services

Patients are asking “how much is this going to cost ME”

� High deductible Plans

� Co-pays/co-insurance

� Ancillary services (anesthesia, pathology, labs, imaging, etc.)

Determining Patient Responsibility

� Discussing money is never easy, especially in healthcare situations

� Patients do not (even try to) understand their insurance coverages

� We must educate our patients about their policies and coverages

� Staff must be trained to answer patient questions

� Access to fee schedules to calculate co-insurances

� Make the calls to determine remaining deductibles

� Call in advance to advise patients of their responsibility

Determining Patient Responsibility

The consequences are real

� For Providers

� People postpone treatment

� Don’t take medication

� For Patients

� Increasing bad debt for providers

� Increasing patient (consumer debt)

� 20% of adults struggle to pay medical bills

� 3 out every 5 bankruptcies due to medical bills; one study 62% with 78% having insurance

� Leading cause of bankruptcy; more than job loss, overuse of credit and divorce. or

Data Elements in a chart

• Name, Address, Telephone, e-mail, SS#, DOB, DOS, Emergency Contact, Employer

Demographic

• Policy #, Group #, Subscriber #, PCP, Referral, Pre-authorization – aka- pre-cert, Verification, Eligibility, Benefits, Primary, Secondary, Active Coverage, Benefits, Deductible, Co-pay, Co-insurance, Out of Pocket, Stop Loss, Insured, Relationship to Insured, Guarantor, Claim, CPT, ICD-9 (now ICD-10) Bills, Statement, EOB, Collection.

Insurance

• Symptoms, consult notes, H&P, Indications, NPO, BMI, Medications, Allergies, Advance Directive, Glucose, BP, prior surgeries, do you smoke ?, do you drink ? Implants ? Dentures,

Clinical

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The anatomy of a visit

• A

• Insurance Eligibility and Verification of benefits

• Advising patient of financial responsibility,

• Collecting $$$$$

• Pre- assessment

• Consenting

• Pre-Op Care

• Post- Op Care

• Discharge

• Follow up call

• Consultation

• Preparation instruction

• H & P

• Diagnosis

• Treatment Plans

• Risks & Benefits

• Advance Directives

•Family members

• Insurance

•Work /School

•Transportation

•Escorts

Social Physician

Insurance RNs/ NPs/ PAs/Techs

Bundling

Links payment for multiple services/providers

Seek out more efficient facilities (ASC vs hospital/OBS)

Cost control

Accountable for outcomes

Assuming risk on following and ancillary services

Reinforces Compliance

Quality Improve

ment

One Fee

Inclusive of all ancillary service

“no surprise bills/

Transparency

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Bundling

More conducive to some procedures where an “episode of care” can be clearly defined

from beginning to end.

� Colonoscopy

� Joint Replacements

� Cardiovascular

� OBG

Key Factors

� Must know your cost

� Assume Risk

� Shared Savings

� Relationship of Multiple parties

Conclusions

� Insurance Verification is a critical component of revenue cycle management

� The current environment is very complex with many factors working against

healthcare providers to collect payments

� Being proactive and transparent helps manage patient expectations and

compliance with financial responsibility

� We have to start looking at services that are conducive to fee bundling.

Proactively discuss with payers to promote cost control and efficiency and

quality of care.

Thank you !

Helen Lowenwirth, MBA, CASC

Administrator

East Side Endoscopy, LLC

www.esecgi.com

hlowenwirth@esecgi.com