Tag: Coverage Discovery

Discovering that a patient's insurance doesn't cover planned care is frustrating for patients and providers. With revenue and patient satisfaction on the line, verifying active coverage should be simple and efficient. However, the process often involves digging through an ever-expanding mountain of data, which consumes valuable time and resources. Increasing patient volumes, frequent payer updates, and new demands for pre-authorization all play a role. Additionally, the impact of nearly 12 million Americans losing Medicaid coverage since April 2023 adds to the challenge.  It's unsurprising that many healthcare organizations no longer rely on manual processes to verify a patient's insurance details. To address these issues, many providers are turning to medical insurance verification software. The CAQH 2022 Index reports that automation of eligibility and benefits verification has increased by 25% over the last 10 years, as providers turn to medical insurance eligibility verification software for more reliable results. This article looks at how these tools are helping healthcare organizations increase their profitability and the questions to consider when selecting the right eligibility verification solution. What is medical insurance verification software? Medical insurance verification software automates the process of checking that a patient's insurance information is current and correct. With just a few clicks (or just a single click when using Patient Access Curator), the software collects data from multiple sources to confirm that prescribed services or treatment are covered by the patient's health plan. Unlike manual processes that involve checking individual payer websites and cross-referencing patient data by hand, an automated solution returns accurate information in an instant. Adoption of this software has grown significantly in recent years because of its ability to drive operational efficiency and reduce revenue loss. More than 90% of medical providers now opt for electronic eligibility verification, according to the CAQH 2022 Index. The report highlights this as a top savings opportunity for the industry, having helped providers avoid almost $81m in costs arising from manual transactions. It's particularly cost-effective for smaller organizations with tighter budgets. How it works: the eligibility workflow Here's what the insurance eligibility verification process looks like in practice: As soon as the user registers the patient, they can make an eligibility request and the software immediately determines whether the patient has coverage on file and whether that coverage has been verified. An optional MBI lookup service can be used to check transactions against MBI databases to see if the patient may be eligible for Medicare. If a patient is eligible for Medicare, the response will confirm the type of Medicare and flag up any missing patient information. If they are not eligible, the transaction will be routed through the regular verification process. For non-Medicare transactions, the software will confirm any other coverage found and provide subscriber details. Benefits of medical insurance eligibility verification software for providers and patients As with all data-driven revenue cycle processes, even the smallest eligibility verification errors can result in denied claims, wasted staff time and lost dollars. Automating the process minimizes the risk of incomplete patient data, outdated insurance information and simple human mistakes. But while accuracy is paramount, the benefits of insurance eligibility software go much further: Boost cash flow and cost savings: Identifying the correct insurance coverage improves the billing process to increase and accelerate reimbursement. With fewer denied claims, more revenue comes in the door and staff time need not be spent on costly rework. Increase operational efficiency: Software automates and streamlines the verification process, saving time and reducing the burden on staff. As labor shortages persist, fewer staff may be available, so any action that makes better use of resources will result in efficiency gains and let staff focus on higher-value tasks. Simplify workflows: Busy providers don't have time for lengthy onboarding exercises or training programs. An eligibility verification product with an intuitive interface that integrates with other information management systems can shortcut the learning curve, while alerts and smart work queues help staff prioritize the right tasks. Leave room to grow: Providers need solutions that can scale in step with increasing patient numbers and administrative complexity. Medical insurance eligibility verification software can adapt to changing needs with minimal disruption. Improve the patient experience: A more reliable verification process means providers can generate accurate and timely cost estimates for patients, which makes it easier for them to understand their financial responsibility and plan for bills. And by eliminating time-consuming manual tasks, software speeds up registration and gives staff more time to focus on patient care. Again, this means more dollars coming in the door. Key features to look for in medical insurance verification software When selecting a platform, healthcare organizations should consider the following questions: Does it pull from reliable data sources? Does the software integrate with existing payer and information management systems? Is the system easy for staff to use? Does it incorporate monitoring and reporting functions? Does the supplier offer ongoing support? Experian Health's Insurance Eligibility Verification solution was developed with these questions in mind. It gathers data from more than 900 payer websites, along with other sources, to generate detailed responses. Advanced search optimization increases the chance of a positive match, so no active coverage slips through the net, while the CAQH COB Smart® Data feature enhances coordination of benefits information for accurate, real-time responses. Providers that already use Experian Health products, such as eCare NEXT®, can access Eligibility through the same interface, so staff can use it right away and generate combined performance reports. One of the major advantages of Eligibility is the optional Medicare beneficiary identifier (MBI) look-up service, as described below. And now, healthcare providers have an additional tool to add to their eligibility arsenal: Patient Access Curator. With Experian Health's recent acquisition of Wave HDC, users can leverage AI-guided data capture technology to quickly check and correct patient insurance information. Patient Access Curator not only verifies insurance eligibility, it also facilitates accelerated coordination of benefits processing, runs automated MBI checks, searches for missing coverage, and analyzes a patient's propensity to pay – all in a single click. Close the coverage gap with medical insurance verification software While insurance verification software improves eligibility review processes, one question remains: how can providers help patients who are found to have invalid coverage? One option is to help patients find alternative coverage, using a solution like Coverage Discovery. Similarly, Patient Financial Clearance can identify patients who may be eligible for Medicaid or charity assistance, and can point them toward manageable payment plans if they have a self-pay balance. In this way, automated solutions can go even further to help providers create a positive patient experience and ultimately reduce the burden of bad debt. As providers embrace the benefits of automation, selecting the right solution is crucial. Tools that integrate workflows throughout patient access and the wider revenue cycle will make it easier to manage change, maximize resources and boost profitability. Find out more about how Insurance Eligibility Verification helps healthcare organizations increase reimbursements with automated eligibility checks.

In a strategic move that will take claims management to the next level, Experian Health recently acquired Wave HDC, a healthcare technology company specializing in AI-guided data capture and curation. The acquisition brings together the two companies' capabilities to offer healthcare organizations faster and more accurate healthcare coverage identification. With this acquisition comes Patient Access Curator, a new solution that uses artificial intelligence (AI) to revolutionize the claims management process. Tom Cox, President at Experian Health, says, “With our vast clearinghouse data resources and Wave HDC's technology and expertise in insurance data capture processes, Experian Health now offers the best eligibility and insurance identification products in the market.” This article gives a run-down of Patient Access Curator and how it helps providers prevent claim denials in seconds. Hear our pre-recorded session from our annual Experian Health High-Performance Summit 2024 (HPS), featuring Exact Sciences and Trinity Health, as they reveal how Patient Access Curator helped their organizations automate eligibility, reduce denials, and more, all with a single click. This session offers live Q&A with Experian Health Product Leadership. Register now Prevent denials on the front end Managing claims effectively – or more specifically, preventing denials – is one of the biggest challenges for providers. In a 2022 survey by Experian Health, 72% of respondents said reducing denials was their top priority, citing reasons including payer policy changes, reimbursement delays, and a rise in the number of errors and denials. Most issues that lead to denials crop up early in the revenue cycle, when information is missed or captured incorrectly during patient registration. For this reason, it makes sense to focus denial prevention strategies on the front end. With so much data to capture, manual strategies are bound to stumble. Unfortunately, many digital tools still require staff to check multiple payer websites and data repositories to verify insurance eligibility and check for any billable coverage that might have been missed. Experian Health's industry-leading claims management products are designed to simplify these processes. The integration of Wave HDC's AI-powered data capture technology strengthens that offer with capabilities previously not available. As Cox says: “Our mission is to simplify healthcare, and this move allows us to quickly scale our portfolio with advanced logic and AI-powered technology to help solve one of the biggest administrative problems providers face today, which is claim denials.” For Jordan Levitt, co-founder of Wave HDC, the merger is a chance to bring their unique technology to more healthcare organizations. “We believe this integration will have a powerful impact for the healthcare industry, improving financial solvency and efficiencies for providers through more accurate medical billing, resulting in potentially more reimbursement, faster.” Introducing Patient Access Curator: Claims management in a single click Wave HDC's technology captures and processes patient insurance data at registration using an “if-then” logic that returns multiple data points from a single inquiry, in 30 seconds. Through Patient Access Curator, registration staff can leverage this technology to collect and verify much of the information they need to compile an accurate claim, with just a single click. In a matter of seconds, they'll have a comprehensive readout of the following: Eligibility verification: PAC automatically interrogates 271 responses, flagging up active secondary and tertiary coverage information to eliminate coverage gaps; Coordination of Benefits (COB): Integrating with eligibility verification workflow, PAC automatically analyzes payer responses to find hidden signs of additional insurances that may be missed by a human eye, and triggers additional inquiries to those third parties to determine primacy, for faster COB processing; Medicare Beneficiary Identifiers (MBI): PAC uses AI and robotic process automation to find and fix patient identifiers so no one misses out on essential support; Coverage discovery and financial status: For patient accounts marked as self-pay or unbillable, PAC automates additional coverage searches, and provides insights into the patient's propensity to pay; Demographics: Lastly, but by no means least, the platform can quickly check and correct patient contact information. Providers can hear more about shifting denials management to the front end of the revenue cycle with Patient Access Curator on a recent on-demand webinar hosted by Jordan Levitt and Jason Considine, Chief Commercial Officer at Experian Health. On the webinar, Levitt explains that Patient Access Curator achieves such speedy results “because the underlying code acts like a Rosetta Stone, automatically translating the language of the user and the health system into the terms required by the payer.” This means data can be transferred easily between interfaces. “The answer isn't multiple clicks, running one transaction at a time. With Patient Access Curator, you can know everything about the patient to run a clean revenue cycle process and propagate only clean data downstream, all within thirty seconds.” Maximize dollars, minimize workload Patient Access Curator moves away from manual methods and verifies eligibility and coverage automatically, quickly and accurately. But the platform promises more than efficiency; with this technology, Wave HDC has prevented denials of over $1 billion since 2020. At a time when revenue cycles are under increasing pressure from changing payer rules, labor dynamics and operational constraints, the new integration offers a long-awaited boost to both reimbursement rates and productivity. Patient Access Curator is available now - learn how your healthcare organization can get started and prevent claim denials in seconds. Learn more Contact us

For Michael Smith, it all began with seemingly innocuous text messages from a PA University Hospital, indicating a wait time for an emergency room visit. A peculiar situation for someone who no longer resided in Philadelphia and hadn't used the hospital system for years. Initially dismissing it as spam, Mike's skepticism deepened when a hospital staffer named Ellen reached out to discuss diagnostic results from an ER visit, he never made.  The revelation was unsettling - someone had registered with Smith's name, and the lack of ID verification raised eyebrows. While the recorded name and date of birth were accurate, the address associated with the account was outdated. A discrepancy that hinted at a more insidious problem.  Undeterred, Smith took matters into his own hands. Following an unsatisfactory conversation with the hospital's billing department, he penned a letter to the privacy officer, expressing his concerns about potential fraud. In his words: "I think there's something going on, that someone is using my information, and the visit and the charges appear to be fraudulent."  Smith's proactive approach sheds light on a crucial aspect of dealing with medical identity theft - swift and assertive action. As cyberattacks on healthcare institutions escalate, individuals must be vigilant in protecting their personal data.   Everyone shares the burden  Whether enrolled in employer-sponsored health insurance or securing coverage through HealthCare.gov, or the individual market, instances of healthcare fraud invariably translate into heightened financial burdens for consumers. Such malfeasance results in elevated premiums and increased out-of-pocket expenses, often accompanied by diminished benefits or coverage. In the realm of employers, both private and governmental entities, healthcare fraud escalates the costs associated with providing insurance benefits to employees, consequently raising the overall operational expenses. For a significant portion of the American population, the augmented financial strain stemming from fraudulent activities could be the decisive factor in realizing or forgoing health insurance.  Yet, the financial ramifications are merely one facet of the impact wrought by healthcare fraud. Beyond monetary losses, this malpractice carries a distinctly human toll. Individual victims of healthcare fraud are distressingly prevalent, individuals who fall prey to exploitation and unnecessary or unsafe medical procedures. Their medical records may be compromised, and legitimate insurance information can be illicitly utilized to submit falsified claims.  It is crucial not to be deceived into perceiving healthcare fraud as a victimless transgression, as its repercussions extend far beyond financial considerations, undeniably inflicting devastating effects.  Healthcare fraud, like any fraud, demands that false information be represented as truth. An all-too-common healthcare fraud scheme involves perpetrators who exploit patients by entering into their medical records' false diagnoses of medical conditions they do not have, or of more severe conditions than they actually do have. This is done so that bogus insurance claims can be submitted for payment. Unless and until this discovery is made (and inevitably this occurs when circumstances are particularly challenging for a patient) these phony or inflated diagnoses become part of the patient's documented medical history, at least in the health insurer's records.  How does medical identity theft happen?  Medical identity theft involves someone using another patient's name name or insurance information to receive healthcare or filing fraudulent claims, posing significant financial and health risks. It can result in bills for procedures the patient has never had, inaccurate medical records, and potentially life-threatening care. Common ways it occurs include database breaches, improper disposal of records, phishing scams, insider theft by healthcare professionals, and theft by family members.  Data breaches in healthcare have reached alarming levels, with the Office of Civil Rights reporting 725 notifications of breaches in 2023, where more than 133 million records were exposed or impermissibly disclosed. Social engineering poses a threat to individual Medicare beneficiaries, but healthcare providers also face risks from ransomware attacks, hacking, and employee errors. Hacking constitutes the dominant threat, accounting for 75% of reportable breaches.  Regardless of how health data is exposed, be it through individual identity theft, hacking attacks, or unintended sharing, any disclosure of payment information increases the risk of healthcare fraud.  Protecting patients and improving their experience  To prevent medical fraud and ensure eligibility integrity, here are some steps healthcare organizations can take:   Implement robust verification processes: Develop and enforce strict protocols to verify patient eligibility and review supporting documents. This includes verifying insurance coverage, confirming the patient's identity, and validating their relationship to the covered individual (e.g., spouse, dependent). Stay updated with legal and regulatory requirements: Stay informed about the latest laws, regulations, and industry guidelines related to medical eligibility and fraud prevention. This could include understanding requirements for reporting changes in eligibility status and keeping up with best practices recommended by regulatory authorities. Train staff on fraud prevention: Provide comprehensive training to all staff members regarding medical fraud prevention, eligibility verification procedures, and red flags to look out for. Staff should be educated on relevant laws and regulations, as well as proper documentation practices. Conduct regular internal audits: Regularly review patient records, claims, and billing processes to identify any inconsistencies or irregularities. Internal audits can help detect potential fraud and ensure compliance with eligibility requirements. Utilize technology and automation: Implement healthcare management systems or software that incorporate automated eligibility verification processes. This can help streamline and improve accuracy in eligibility determinations, reducing the risk of fraudulent benefits being provided. Encourage patient engagement: Educate patients about their responsibilities in maintaining accurate eligibility information. Promptly notify patients about the importance of reporting changes in their circumstances (e.g., marital status, employment status) that may affect their eligibility for medical benefits. Report suspicious activity: Train staff to recognize and report any suspicious activity or potential fraud. Establish clear reporting channels within your practice and encourage a culture of transparency and accountability. Stay vigilant: Stay alert for emerging trends, schemes, and new types of medical fraud. Regularly review industry updates, attend relevant workshops or seminars, and participate in fraud prevention initiatives to stay informed about evolving threats and prevention strategies. By implementing these measures, healthcare organizations can help safeguard their medical practices against medical fraud and preserve the integrity of eligibility determinations.   Finding the right partner  Healthcare fraud is a serious crime that affects everyone and should concern everyone—government officials and taxpayers, insurers and premium-payers, healthcare providers and patients—and it is a costly reality that can't be overlooked. By taking steps to find the right partner along the way, providers are helping to protect the integrity of the nation's healthcare system. Experian Health works across the healthcare journey to improve the patient experience, make providers more effective and efficient, and enhance and simplify the overall healthcare ecosystem.   Learn more or contact us to see how Experian Health's patient identity solutions can help healthcare organizations prevent medical ID theft. 

Racing against the clock to troubleshoot billing issues, claims bottlenecks and staffing shortfalls are just part of an average day for healthcare revenue cycle managers. It's hard enough to maintain the status quo, never mind driving improvements in denial rates and net revenue. With integrated artificial intelligence (AI) and automation, many of these challenges in revenue cycle management (RCM) can be alleviated – and with just a single click. Real-time coverage discovery and coordination of benefits software reduces errors and accelerates accurate claim submissions. This eases pressure on busy RCM leaders, so they have the time to focus on improving the numbers that matter most. Top challenges in revenue cycle management Efficiency is the currency of revenue cycle management. Maximizing resources is not just about keeping dollars coming in the door but about making the best use of each team member's time and expertise. The ever-present call to “do more with less” is probably the biggest challenge. Breaking that down, some specific concerns that consume more time and resources than RCM managers would like, are: Complex billing procedures: With hundreds of health payers operating in the US, each offering different plans with different requirements, providers have their work cut out to ensure claims are coded and billed correctly. Any errors in verifying a patient's coverage, eligibility, benefits, and prior authorization requirements can lead to delays and lost revenue. More claim denials: Inaccurate patient information and billing codes guarantee a denial. Beyond the rework and revenue loss, denied claims leave patients with bills that should not be their responsibility to pay, causing confusion, frustration, and higher levels of bad debt. Garbage in, garbage out. Patient payment delays: A few years back, patients with health insurance represented about a tenth of bills marked as bad debt. Now, this group holds the majority of patient debt, according to analysts. The rise in high-deductible health plans combined with squeezed household budgets means patients are more likely to delay or default on payments. Providers must be on the lookout for ways to help patients find active coverage and plan for their bills to minimize the impact of these changes. How can AI-powered revenue cycle management solutions help? The Council for Affordable Quality Healthcare (CAQH) annual index report demonstrates how much time can be saved using software-based RCM technology. Case in point: switching from manual to automated eligibility and benefits verification could save 14 minutes per transaction. This adds up quickly when daily, monthly, and yearly transactions are factored in. Predictive analytics can be used to pre-emptively identify and resolve issues and support better decision-making, giving providers a head start on those elusive efficiency gains. Three specific examples of how automation, AI and machine learning can streamline the front-end and solve challenges in revenue cycle management are as follows: 1. Upfront insurance discovery to find and fill coverage gaps Confirming active coverage across multiple payers gives patients and providers clarity about how care will be financed. But this can be a resource-heavy process when undertaken manually. Coverage Discovery uses automation to find missing and forgotten coverage with minimal resource requirements. By unearthing previously unidentified coverage earlier in the revenue cycle, claims can be submitted more quickly for faster reimbursement and fewer write-offs.With Experian Health's recent acquisition of Wave HDC, clients now have access to faster, more comprehensive insurance verification software solution. The technology works autonomously to identify existing insurance records for patients with self-pay, unbillable, or unspecified payer status and correct any gaps in the patient's coverage information. The patient's details are updated automatically so that a claim can be submitted to the correct payer. 2. Real-time eligibility verification and coordination of benefits As it gets harder to figure out each patient's specific coverage details, it also makes sense to prioritize automated eligibility verification. Eligibility Verification uses real-time eligibility and benefits data to confirm the patient's insurance status on the spot.Similarly, Wave's Coordination of Benefits solution, now available to Experian Health clients through Patient Access Curator, integrates directly into registration and scheduling workflows to boost clean claim rates. It automatically analyzes payer responses and triggers inquiries to verify active coverage and curate a comprehensive insurance profile. This means no insurance is missed, and the benefits under each plan can be coordinated seamlessly for more accurate billing. 3. Predictive denials management to prevent back-end revenue loss Adding AI and machine learning-based solutions to the claims and denials management workflow means providers can resolve more issues pre-claim to minimize the risk of back-end denials. Use cases for AI in claims management might include: Automating claims processing to alleviate staffing shortages Reviewing documentation to reduce coding errors Using predictive analytics to increase operational efficiency Improving patient and payer communications with AI-driven bots All of these contribute to a front-loaded denials management strategy. While prevention is often better than a cure, AI can be equally effective later in the process: AI AdvantageTM arms staff with the information they need to prevent denials before they occur and work them more efficiently when they do.Whatever new challenges may pop up on the RCM horizon, AI and automation are already proving their effectiveness in helping providers save time and money. But more than that, they're giving busy RCM leaders the necessary tools to start future-proofing their systems for persistent and emerging RCM challenges. Learn more or contact us to find out how healthcare organizations can use AI and automation to manage current revenue cycle management challenges with a single click.

More than 13 million Americans have lost Medicaid coverage since continuous enrollment came to an end in April 2023. Unwinding the emergency provisions requires states to determine which individuals remain eligible for Medicaid, leading to widespread disenrollment. The Medicaid redetermination process created a major admin burden for agencies and providers, and now, the impact of that burden on patients has become clear: more than 7 million of those who lost coverage were disenrolled because of administrative processes, and not due to ineligibility. While some will find coverage elsewhere, many will be left without insurance. These coverage gaps disrupt health services with adverse effects for patients and providers. In a recent webinar, Kate Ankumah and Mindy Pankoke, Product Managers at Experian Health, reflect on the Medicaid redetermination process and discuss how providers can mitigate the effects of redetermination heading into 2024. Recap: Medicaid continuous enrollment provision timeline How does the Medicaid redetermination process work? The redetermination process, led by state agencies, involves reviewing Medicaid rosters and automatically renewing coverage for individuals that still qualify, based on benefits or other government data. When coverage cannot be confirmed automatically, states need to reach out to patients to fill in the gaps. If the individual is no longer eligible (or does not provide the necessary data), they will be removed from coverage lists. Many patients are confused about the process and may not even realize they're no longer covered, leading to delays and distress when they try to access care. This blog post breaks down the 5 things providers can do if a patient loses Medicaid coverage. 1. Tighten up insurance eligibility verification processes During the webinar discussion, Kate Ankumah explains that implementing a reliable eligibility verification tool is essential to reduce financial risk, increase revenue and streamline staff workflows: “With our Eligibility product, we connect to more than 900 payers with search optimization. Providers don't need to send the same information over and over – we'll run through the search options ourselves and find the information as quickly as possible. Then we standardize the data so front desk staff can read all the responses in the same way. We also build in alerts. A couple of clients have alerts set up for Medicaid redetermination dates that pop up if a patient is due for redetermination so the front desk staff know to have a conversation with them about it.” Eligibility also includes an optional Medicare beneficiary identifier (MBI) lookup service, to check if any patients who may have been disenrolled from Medicaid are now eligible for Medicare. 2. Find missing coverage with Coverage Discovery Providers may also want to automate the search for any active coverage that may have been overlooked. Coverage Discovery searches for possible billable government or commercial insurance to eliminate unnecessary write-offs and give patients peace of mind. Using advanced search heuristics, millions of data points and powerful confidence scoring, this tool checks for coverage across the entire patient journey. If the patient's status changes, their bill won't be sent to the wrong place. In 2021, Coverage Discovery identified previously unknown billable coverage in more than 27.5% of self-pay accounts, preventing billions of dollars from being written off. 3. Quickly identify patients who may be eligible for Medicaid and financial assistance The lack of clarity around enrollment and eligibility is disruptive for claims and collections teams. How can they handle reimbursements and billing efficiently if financial responsibility is unclear? Denial rates are already a top concern for providers, and staff cannot afford to waste time seeking Medicaid reimbursement for disenrolled patients. Patient collections also take a hit when accounts are wrongly designated as self-pay. With Patient Financial Clearance, providers can quickly determine if patients are likely to qualify for financial support, then assign them to the right financial pathway, using pre- and post-service checks. Self-pay patients can be screened for Medicaid eligibility before treatment or at the point of service, and then routed to the Medicaid Enrollment team or auto-enrolled as charity care if appropriate. Post-visit, the tool evaluates payment risk to determine the most suitable collection policy for those with an amount to pay and can set up customized payment plans based on the patient's ability to pay. Patient Financial Clearance also runs back-end checks to catch patients who have already been sent a bill but may qualify for Medicaid or provider charity programs. This helps secure reimbursement and means patients are less likely to be chased for bills they can't pay. 4. Screen and segment patients according to their propensity to pay Optimizing collections processes is always a smart move for providers, but particularly now that federal support has ended. Collections Optimization Manager uses advanced analytics to segment patient accounts based on propensity to pay and send them to the appropriate collections team. Drawing on Experian's consumer credit data, Collections Optimization Manager's segmentation models are powered by robust and proprietary algorithms. These models screen out Medicaid and charity eligibility, so collections staff focus their time on the right accounts. Case study: See how University of California San Diego Health (UCSDH) increased collections from around $6 million to over $21 million in just two years using Collections Optimization Manager. 5. Make it simpler for patients to manage and pay bills The reality is that many patients affected by the unwinding of continuous enrollment will be on low incomes. When more than half of patients say they'd struggle to pay an unexpected medical bill of $500, providers should make it easier for patients to gauge their upcoming bills. Patient Financial Advisor and PatientSimple® can help patients navigate the payment process with pre-service estimates, access to payment plans and convenient payment methods they can access on a computer or mobile device. Together, these tools can help providers manage Medicaid changes efficiently and offer extra support to patients who may be facing disenrollment. Watch the webinar to see the full discussion on how Medicaid redetermination is affecting providers and find out how Experian Health's digital solutions can help healthcare organizations quickly and easily verify insurance coverage.

“We wanted the right technology that could look for insurance coverage for self-pay patients without the need for us to increase our manpower. The cost savings were a big win for the department.” — Brent Rikhoff, Director of Pre-Access, UCHealth Challenge UCHealth is an integrated health system with a network of 12 hospitals and more than 30,000 employees. At the height of the COVID-19 pandemic, UCHealth maintained its commitment to an excellent patient experience by giving all patients access to tests and vaccinations. Costs for uninsured and self-pay patients could be recovered under the Health Resources and Services Administration's (HRSA) COVID-19 Uninsured Program (UIP), but only after confirming that the patient had no relevant active coverage. If they missed this step, UCHealth would be landed with bad debt, increasing collection costs and unwanted audits: they needed a reliable way to track and verify insurance coverage accurately and in real-time. Solution UCHealth chose to use Coverage Discovery® after experiencing positive results with Experian Health's Eligibility solution. Coverage Discovery allowed them to scan the entire revenue cycle for billable commercial and government coverage that patients may have been unaware of or forgotten about. The tool gave UCHealth access to Experian's proprietary databases, including employer group mapping and patient search history, so they could track and verify potential coverage in multiple locations. This made it much easier to find insurance information for plans without a self-pay search feature. After seeing positive results, UCHealth expanded their use of Coverage Discovery to self-pay and emergency department patients. This helped them root out discrepancies in patient accounts and prevent accounts from being misclassified as bad debt or charity. Uncovering additional active coverage was also a major benefit for patients. Discover the top 4 strategies to optimize patient collections while delivering a more compassionate financial experience for patients. Outcome Thanks to Coverage Discovery, UCHealth achieved the following results: Over $62 million in insurance payments in 2022, a 25% increase from 2021, includes payments from their top three payers $45 million in coverage found between May 2022 and May 2023 Over $3.5 million in collection costs savings in 2022 Overall, Coverage Discovery has helped UCHealth create a more streamlined approach to verification and billing. The batching feature made it easy for staff to process the backlog of patient accounts awaiting insurance verification, while access to large, current datasets facilitated more accurate billing. Director of Pre-Access at UCHealth, Brent Rikhoff, said the ability to integrate Coverage Discovery with Epic® enabled the team to achieve proper reimbursement for services rendered. Expanding the solution to include Medicaid coverage identification would be an obvious next step for UCHealth, following this impressive return on investment. Learn more about how Coverage Discovery identifies missing and forgotten billable coverage, so healthcare providers can get fully reimbursed while maintaining an outstanding patient experience.

In July this year, the Centers for Medicare & Medicaid Services (CMS) reported that a data breach in a contractor's network may have compromised the data of more than 600,000 current Medicare beneficiaries. The breach, which occurred in May 2023, involved a vulnerability in file transfer software that enabled an unauthorized party to access beneficiaries' personally identifiable information (PII) and protected health information (PHI). Some patients were issued with new Medicare Beneficiary Identifiers (MBIs) following the incident. The contractor also offered two years of Experian credit monitoring at no cost to those affected. However, providers may see an increase in patients who are confused or concerned about using their MBI card. Experian Health's MBI Lookup service can help providers ensure that Medicare eligibility verification remains as efficient as possible. Thousands of beneficiaries issued new MBI numbers In response to the breach, CMS announced that 47,000 individuals would be mailed new MBI cards with new MBI numbers. However, as 612,000 patients were affected by the breach, there may be a significant number of people whose MBIs may change without notice. Since these individuals will not be able to use their old MBIs when trying to find Medicare coverage and benefits, there could be confusion among patients and providers who rely on MBIs to confirm a patient's eligibility for Medicare coverage. It could also affect billing processes and claim status inquiries. Experian Health reached out to CMS for clarification and received the following guidance: If a Medicare beneficiary's MBI number has changed, then their old (now inactive) MBI will return an AAA72 error when attempts are made to confirm coverage using the HIPAA Eligibility Transaction System (HETS). The HETS 270/271 platform will accept historical 270 requests that use the patient's new MBI. Old MBI numbers will only be accepted if that number was active during the Date(s) of Service noted on the request. Providers should note that some patients may inadvertently use invalid MBI numbers and review processes for verifying Medicare eligibility accordingly. Verifying Medicare eligibility with Experian Health's MBI Lookup tool Verifying active coverage can be a painstaking process, but it's a vital step to confirm that planned services will be covered by the patient's insurance provider. If a patient is unaware or cannot demonstrate eligibility for Medicare, then the provider cannot make a claim for reimbursement, and the patient may be left to pay a bill they cannot afford. Finding active coverage helps providers reduce the risk of bad debt. Experian Health's Insurance Eligibility Verification speeds up this process by accurately confirming coverage at the time of service. The process comes with an optional MBI Lookup feature, which checks transactions against MBI databases to see if the patient may be eligible for Medicare. If the patient has forgotten their MBI card, the tool will check to see if they're included in the database, using their name, date of birth, and Social Security Number (SSN) or Health Insurance Claim Number (HICN). The MBI Lookup service triggers on 270/271 transactions in the following cases: Where the transaction fails because the subscriber is not found or their MBI number or other identification is missing or invalid (a “Traditional Medicare Failure”) Where a commercial 270 inquiry returns a “Medicare Advantage Plan” or “Managed Care Plan” indication on the “Other Payer” or “Other Coverage” section of the 271 response Where a commercial 270 transaction returns a failed response and the patient is aged 65 or older. If the provider's system attempts to use a patient's old number, and the patient does not realize that they have a new number or card, MBI Lookup will find and verify their new MBI. When the tool is triggered, it finds active and verified MBI numbers in 60% of cases on average. Find coverage faster with automated discovery tools Kate Ankumah, Principal Product Manager of Eligibility Verification and Alerts at Experian Health, says the automated MBI Lookup service has proven especially useful during times of change: “Providers relied on this service to verify Medicare coverage quickly when the pandemic hit, just as the industry was adjusting to the use of MBIs instead of their legacy HICN. Now, MBI Lookup can help providers smooth out the impact of data breaches involving Medicare beneficiaries with minimal fuss. It's a reliable way to give patients clarity without placing any undue burden on staff.” Insurance Eligibility Verification can be used alongside other automated coverage identification tools, such as Coverage Discovery®. Coverage Discovery scans government and commercial payer databases throughout the patient journey to find any previously unknown or forgotten coverage, eliminating the need for manual inquiries. Using multiple sources of data and tried-and-tested algorithms, these tools work together to locate coverage for patients, giving patients peace of mind and helping providers avoid uncompensated care. Both tools can be accessed via the eCareNext® platform, so staff can view eligibility responses and manage work queues through a single interface. And of course, this recent breach is a stark reminder of the need to protect patient data. Using a single vendor with integrated software and data solutions can help reduce the risk of data getting into the wrong hands. Find out more about how Experian Health's Eligibility Verification solution and MBI Lookup tool can help providers verify active coverage and give patients peace of mind following a data breach.

Patient collections go to the heart of the debate about mission versus margin. As healthcare providers navigate the delicate balance between their mission to heal and the need to run a successful business, optimizing patient collections becomes a critical challenge. The weight of asking patients for payment is not lost on providers, especially considering the financial burden many patients already face due to medical expenses. It doesn't help that healthcare providers understand patients' struggles with medical debt. A 2023 Consumer Financial Protection Bureau report stated, “Many people experience unexpected health shocks that affect their financial well-being as much as, or even more than, their physical health.” As of June 2021, the United States recorded $88 billion in consumer debt to hospitals; 58% of all consumer debt is healthcare-related. One recent Experian Health and PYMNTS report shows that one-fifth of patients experienced financial distress by spending more on healthcare than they could afford. With healthcare costs rising, patients and healthcare providers feel a great deal of pain around budget balancing. Rising co-pays affect consumers in tandem with healthcare providers experiencing declining reimbursement. It's an untenable situation, but healthcare providers are increasingly turning to four critical strategies driven by technology solutions to ease these collections conundrums. Four alternative strategies to optimize patient collections In this blog, we explore four key strategies fueled by technology solutions that help healthcare organizations optimize patient collections while upholding compassionate care. 1. Do ongoing reviews of patient finances with the possibility of charity eligibility in mind While the unemployment rate is currently low compared to pandemic numbers, providers need to remember that just a few years ago, four in 10 Americans were without work for 27-weeks or longer. Americans are still playing catch up, and the data tells us nearly half of patients who reschedule their healthcare appointment do so related to cash flow concerns. Healthcare providers can help by working presumptive charity screenings into their collection workflows throughout the patient journey. Experian Health's Patient Financial Clearance software uses advanced analytics and data to analyze individual patient accounts and determines their ability to pay. This technology allows front desk personnel to quickly choose the most appropriate financial pathway for each patient. Patient Financial Clearance brings healthcare personalization to the most delicate part of the provider/consumer relationship, allowing staff to adjust their approach to suit each patient's financial abilities. 2. Using automation to find patient payment coverage Manual processes for patient financial arrangements slow down registration and ultimately miss potential payment resources. Unidentified coverage opportunities leave hospitals with over $745 billion in uncompensated care costs annually. The solution lies within Experian Health's Coverage Discovery software. This tool automatically scans the patient's account throughout their healthcare journey, searching for alternative payment methods to help patients improve their financial burden. Luminis Health leveraged Coverage Discovery and found more than $240k in active coverage on average per month in 2021.  3. Implementing compassionate billing methods to improve the collections experience Streamlining the registration process while discovering payment resources are two critical ways to create a more compassionate billing process and improved patient experience. Nearly one-quarter of patients face an unexpected medical bill after care delivery. Creating transparency between provider billing and the patient requires better technology to build personalized payment plans. Collections Optimization Manager makes payment collections easier by creating data-driven payment plans and individualized communications for each patient. This software can fully integrate with commonly used provider systems to connect with the patient from start to finish. It's a smarter and faster way to collect patient payments. 4. Using data for better collections In healthcare, software applications are only as good as the data behind them. While healthcare organizations have relied on behavioral and demographic datasets, adding a layer of credit data informs the revenue cycle in a way that adds enormous financial value to these organizations. With tools like Collections Optimization Manager, unpaid accounts are monitored for changes in a patient’s contact information or ability to pay. When a patient becomes employed, pays off delinquent accounts, or shops for credit, the in-house staff or the collection agency working the account is notified.  These combined datasets lay the groundwork to inform the payment collections process. Case study: Using technology for better healthcare collections Healthcare organizations like Stanford Health Care leverage technology as part of their strategies to optimize patient collections—and improve the patient experience with their system. The provider handles over two million patients annually and uses Experian Health's Collections Optimization Manager software to improve their bottom line. The software analyzes individual patient data at the point of service, segmenting patient accounts on their ability to pay. The software recovered significant revenue for the system while creating a more personalized approach to patient payment requirements. Missing coverage at the front desk resulted in significant revenue losses for the system, unnecessarily shifting payment burdens to patients. With Coverage Discovery, the system uncovered patient reimbursement resources, eliminating the need to write off or send these accounts to collections. Together, these tools achieved stunning results: More than $4m in average monthly payments More than $1 million in efficiency gains Savings of nearly 700 hours monthly by automating customer account screening Nearly 30% of all Coverage Discovery reviews found patient payment resources Experian Health: providing strategies and compassionate, personalized software to optimize patient collections With millions of Americans struggling with medical debt, healthcare providers must proactively address the challenges surrounding patient collections. By embracing innovative strategies powered by technology, providers can strike a balance between compassionate care and financial sustainability. Optimize patient collections with Experian Health's coordinated ecosystem of intelligent technologies, designed to simplify healthcare, promote customer-centricity, drive data-driven decision-making, and generate sustainable revenue.

Finding previously unidentified insurance coverage is a high-stakes treasure hunt for healthcare providers. If patients are unaware of active coverage or eligibility for Medicare and Medicaid, they will be left footing a bill that could have been covered by a payer. If they can't afford it, their account may end up being written off to bad debt, and providers will miss out on reimbursement opportunities, leaving millions of revenue dollars on the table. Hunting down missing or forgotten coverage on the spot is a challenge for providers, particularly if the patient does not have a Social Security Numbers (SSN) or the payers in question do not use SSNs to verify eligibility. It's a problem worth solving though and can improve the patient financial experience while preventing avoidable revenue loss. The shift away from Social Security Numbers Historically, providers have used demographic information like Social Security Numbers (SSN) to verify patient identities and locate coverage information. Without a unique patient identifier, SSNs were a stable way to link a person's health information across multiple health systems and payers. However, the use of SSNs for identification and verification purposes has dropped in recent years due to concerns about patient privacy and the risk of identity theft: SSNs give identity thieves a mechanism to assume a person's identity and access financial information and health records illegally. Moreover, SSNs are unreliable identifiers, as it is possible for more than one person to use the same number. Recognizing the need for more secure and trustworthy identifiers, many payers have moved away from SSNs. In 2018, the Centers for Medicare & Medicaid Services began the process to remove SSN-based Health Insurance Claim Numbers (HICNs) from Medicare cards, replacing them with Medicare Beneficiary Identifiers (MBIs). These are now the primary means of checking a person's identity for Medicare transactions like billing, eligibility status and claim status. Similarly, many health plans also shifted away from using SSNs as primary identifiers, instead opting for member IDs or other secure identifiers to verify and track coverage for their members. Find billable coverage with historical data With demographic searches on the decline, providers need a more efficient and reliable way to search for coverage. As a data-driven company with a historical repository of claims data, Experian Health is uniquely positioned to help providers search for coverage. Combining search best practices, multiple proprietary databases and historical information, Experian Health's Coverage Discovery® locates patients' billable commercial insurances that were unknown or forgotten, and combs through Medicare and Medicaid coverage. This flags accounts that may have been destined as a write-off or charity and maximizes reimbursement revenue by identifying primary, secondary and tertiary coverage. Not only do fewer accounts go to bad-debt collections, but providers can automate the self-pay scrubbing process. In 2022, Coverage Discovery tracked down billable coverage in almost 30% of self-pay accounts and found more than $64.6 billion in corresponding charges. Closing the coverage gap caused by Medicaid disenrollment Coverage Discovery offers another important benefit: helping providers offer additional support to patients on lower incomes who find themselves without Medicaid, at least for a short time, following the end of continuous enrollment. As of July 2023, more than 1.6 million Medicaid enrollees were disenrolled. Providers can use the tool to confirm whether Medicaid coverage remains in place, or to uncover any additional billable government or commercial insurance that could give patients peace of mind. Patient Financial Clearance can also help screen patients for Medicaid eligibility before or at the point of service, then route them to the Medicaid Enrollment team or auto-enroll them in charity care if appropriate. Case study: Read the case study to find out how Luminis Health used Coverage Discovery to locate $240k in billable coverage each month. Leverage technology to locate unidentified coverage Thanks to advanced tools like Coverage Discovery and Patient Financial Clearance, it's much easier for providers to locate alternative coverage options for patients, using multiple sources of data. These tools leverage secure identifiers and comprehensive searches across databases, allowing providers to reclaim revenue that may otherwise go unclaimed, and reassuring patients that they won't be left holding an unexpected bill. Find out more about how Coverage Discovery can help find previously unidentified coverage and reduce bad debt.