Rejection Hurts: How Advances in Patient Engagement Are Helping Practices Drive Down Claim Denials

When it comes to the U.S. healthcare system, perhaps no topic is the subject of greater debate than access to affordable health insurance. From wellness checks to surgeries, patients and practices rely on insurance providers to cover the expense of these essential, often life-saving services, especially as the cost of office visits, treatments and medication continue to rise. Yet, unfortunately, not every American has the healthcare coverage they need. According to a September 2019 report issued by the U.S. Census Bureau (numbers reflect the country’s status in 2018), here are the stats:

• Who’s insured? 91.5% of the population had some sort of health insurance coverage for the year or part of it, either public or private. This number shows a decrease from 92.1% the previous year.
• How are they insured? 67.3% of the population held private health insurance coverage, while 34.4% had public coverage. Employer-based insurance covered 55.1% of individuals with coverage.
• Who’s not insured? 8.5% of the population – 27.5 million people – did not have health insurance during the year. This is an increase from 7.9% or 25.6 million people the previous year. 5.5% of children under the age of 19 were uninsured, a rise of .6% over the previous year.

That’s right: 27.5 million U.S. citizens were without health insurance. Fast forward six months from the publication of this report and the problem has grown exponentially, with tens of millions of jobs lost due to the COVID-19 pandemic. Of course, given so many individuals are insured via their employers, a job loss or a job change is likely to have major repercussions on coverage status.

Yet, despite the uncertainty, Americans still need to see a doctor due to an emergency, a wellness visit, or a scheduled procedure. This means that healthcare practices need to go the extra mile to ensure they are reimbursed for the services and treatments they administer. According to the U.S. Department of Labor, one claim in seven is initially rejected – totaling more than 200 million denied claims a day and representing huge financial hits (or massive headaches and hassles, at a minimum) for practices and patients alike. What can a practice do to slash their claim denial rate? A few simple measures can make all the difference:

• Reduce the number of billing and administrative errors. Claims are often denied due to wrong or incomplete patient data. More than 70% of patient records contain incorrect information, which is easy to believe, given the amount of manual paperwork required across patient engagement touchpoints. What’s worse? Much of this information-gathering is repetitive, creating multiple chances for error during the re-collection of information. By automating the process with a patient-engagement platform and electronic self-checking solution like Clearwave, patients enter their information once via a touchscreen kiosk or mobile device before the visit. That information is then verified and automatically tagged to the patient record going forward. There is no need for pen and paper or handwritten documentation to enter at a later point – and, thus, fewer opportunities for data-entry mistakes.
• Take advantage of automatic eligibility verification. In addition to improving data accuracy, patient-engagement and self-check-in solutions can simplify and expedite eligibility verification. Once the patient has updated their insurance-provider details, the system can cross-check their information with specifics about their visit, procedural codes, treatment information, and other relevant data to confirm whether their policy will cover the visit and any associated services. If not, or if the patient lacks coverage altogether, the system can notify front-desk staff, who can then present alternative payment options to the patient before leaving the office. These systems can also allow patients to pay their balance discreetly via a kiosk, tablet or other type of mobile device, which gives the practice another opportunity to collect fees without putting the patient in an uncomfortable position.
• Determine before a visit whether a procedure requires pre-authorization. Learning that a procedure requires the proper pre-authorization at the end of the appointment is too late. In an ideal scenario, patients would be alerted to the requirement and pre-authorizations would be secured well before they arrive on-site or log in for their telehealth session. The right patient-engagement and self-check-in solution with mobile capabilities – like Clearwave’s Mobile Precheck™ – give practices the ability to do exactly that. When the appointment is scheduled, patients may immediately receive a notification via email or text informing them that the visit or procedure requires pre-approvals, and then walk them through the process for getting those approvals before the visit. This ensures specialty practices don’t get left holding the bill because they provided a service that wasn’t authorized by the patient’s primary care physician or other designated healthcare practitioner.
• Don’t let time lapse between service and submission. A claim must be filed within a certain number of days post-appointment for it to be accepted. This may seem like a simple deadline to meet – unless your front-office staff or the practitioners themselves are stretched too thin, away on vacation, out sick or unable to pull together the necessary paperwork for any other reason. By automating the patient-engagement process, data is collected, verified and submitted in real-time with complete accuracy, ahead of the deadline. This cuts down on the administrative workload and makes late submissions a thing of the past.

From out-of-network physician choices to mistakes during data entry, there are many reasons why an insurance claim is denied. Fortunately, patient engagement and self-check-in technology, coupled with the appropriate best practices, will dramatically lighten the eligibility-verification burden. The result:  a reduction in claim denials, improvements in cash flow and practice profitability – and a boost to patient satisfaction.