Tag: Coverage Discovery

With the ability to be applied across many different areas – from disease prediction to claims management and administrative tasks – data and analytics in healthcare is booming. In fact, according to a Grand View Research report, the global market for data analytics was valued in 2022 at $35 billion and is expected to increase at a compound annual growth rate of 21.4% until 2027. So, why the rapid growth? How can healthcare data analytics be used across the healthcare revenue cycle? The role of data and analytics in healthcare Historically, there has been a large amount of healthcare data being generated, but the industry has struggled to properly leverage this data into useful insights that improve patient outcomes, operations, or revenue. Today, with increasingly advanced data analytics, healthcare providers are using real-time data-driven forecasts to stay nimble and pivot quickly in rapidly changing healthcare and economic environments. And there is more data collaboration between healthcare organizations to convert analytics-ready data into business-ready information, thanks to the ability to automate low-impact data management tasks. Data-derived intelligence is also now easier to share with colleagues, third parties and the public. Types of healthcare data analytics methodologies and tools Healthcare data analytics involves several different types of methodologies and tools – all of which can be applied to various aspects of revenue cycle management. For example, descriptive analytics allows organizations to review data from the past to gain insights about previous trends or benchmarks. Predictive analytics, on the other hand, uses modeling and forecasting to help predict future results. When a strategic course of action is needed based on certain data inputs, prescriptive analytics is used. If a provider wants to take a deep dive into raw data to uncover patterns, outliers, and interconnection, they may employ discovery analytics. There are also generally three categories of technology-driven tools that can help collect and convert raw data into usable insights during the revenue cycle, including: Solutions that gather data from a wide variety of sources, such as patient case files, machine-to-machine data transfers, and patient surveys Programs designed to scrub, validate, and analyze data in response to a specific question being researched Software created to leverage the results produced by the analysis into actionable suggestions that be applied to meet specific goals Applying data analytics to maximize revenue “There are many things driving near-constant change in the healthcare revenue cycle, including shifting reimbursement, evolving value-based payment models, growing regulatory pressures, and increasing provider risk and patient responsibility,” says John Menard, VP of Product, Analytics, at Experian Health. “Healthcare organizations are also adapting to value versus volume reimbursement models, requiring revenue cycle leaders to lean into leveraging data analytics to improve not just operational efficiency, but patient financial experience and quality outcomes as well." Here's a closer look at how data analytics can help with revenue cycle management: Assessing patient finances From registration to collections, data analytics can play a key role at every step of the patient journey – and revenue cycle. Not only can the right data analytics tools help healthcare organizations better assess a patient's individual financial circumstances, but they can also help providers create accurate estimates and payment plan recommendations. Data-driven technology can help providers reduce surprise billing through more transparent pricing, helping patients navigate the cost of care and providing more timely patient communication. Digital solutions can help improve the patient financial journey by: Providing a self-service patient portal – With a solution like PatientSimple, patients get convenient 24/7 access to self-service account management tools. They can use the online portal to log into their healthcare account to securely process payments, request or review payment estimates, and schedule appointments. The portal also provides patient access to pricing information, plus the ability to apply for financial assistance or set up payment plans. With easy-to-use patient online tools, patients are more likely to meet their self-pay responsibilities and providers get paid more quickly as a result. Offering payment solutions – To collect payments with confidence, healthcare providers can utilize comprehensive data collection and advanced analytics through a digital solution like Patient Financial Clearance. With this solution, providers use a patient's financial data to quickly assess a patient's propensity and likelihood to pay prior to treatment. When appropriate, providers can then offer empathetic financial counseling and connect those that potentially qualify to financial assistance programs. By applying data analytics to this payment solution, healthcare organizations can increase point-of-service collections while reducing bad debt—in real-time. Providing patients with more accurate estimates – A recent Experian Health study found that 4 in 10 patients said they spent more on healthcare than they could afford. However, when patients know the expected cost of their care up front, they feel more empowered and make better decisions. Patient Estimates lets providers create more accurate estimates, eliminate manual tasks and improve patient satisfaction. Plus, it allows providers to automate and standardize their price transparency practices, which can help healthcare organizations meet regulatory requirements, create a more positive patient experience and increase revenue at the point of service. Reduce denied claims According to Experian Health's 2022 State of Claims survey, denied claims are on the rise with 42% of providers reporting that denials increased in the past year. 47% of respondents also said improving clean claims rates was a top pain point. Digital solutions can help providers reduce denied claims and increase revenue by: Automating claims management – With a solution like ClaimSource®, providers can automate their claims management systems – helping to ensure claims are clean before they are submitted to a government or commercial payer. Using an automated solution also allows providers to streamline the claims management process from a single web application. With ClaimSource, providers can easily analyze claims, payer compliance and insurance eligibility. Plus, it allows staff to prioritize their workload and focus on high-impact accounts – resulting in claims denial rates of just 4% compared to the industry average of more than 10%+. Optimizing efficiencies through artificial intelligence – Incorporating artificial intelligence (AI) into an automated claims management solution enhances the claims process in two key moments: before claim submission and after claim denial. AI Advantage™ integrates seamlessly with ClaimSource to continuously learn and adapt to ever-changing payer rules. The solution features two AI offerings, AI Advantage – Predictive Denials and Denial Triage, which can be customized to prioritization thresholds. Verify insurance and patient information Missing patient healthcare data can be a headache for providers to hunt down but looking for active coverage is often necessary. Providers must contend with a range of factors impacting patient coverage – including forgotten coverage, inadequate coverage, patients being misclassified as self-pay and regulatory changes, particularly with Medicaid and Medicare coverage. Implementing digital solutions can help providers use data to verify and find missing patient health insurance coverage, optimize patient collections, and boost revenue by: Utilizing automated, real-time insurance verification – Verifying patient coverage prior to service using a digital solution, such as Experian Health's Insurance Eligibility Verification. This tool can help providers experience fewer payment delays and claim denials. Plus, verifying insurance with automated insurance eligibility and benefits data improves cash flow, reduces claims denials and speeds up payments, including Medicare reimbursements. Patients also feel empowered with accurate payment estimates and accelerated registration, leading to a better patient experience overall. Improving collections with better data – With Collections Optimization Manager, providers can screen out bankruptcies, deceased accounts, Medicaid and other charity eligibility ahead of time. Through targeted collection strategies, providers can leverage actionable insights to focus on high-value accounts. Plus, predictive algorithms and data-driven rules help providers route and distribute accounts to the right collectors and agencies, controlling overall collection costs. This solution also connects providers to live support from an experienced optimization consultant that will help develop a tailored collection strategy through data evaluation and industry knowledge. Finding unidentified coverage – In 2022, Coverage Discovery tracked down previously unknown billable coverage in 28.1% of self-pay accounts, finding more than $64.6 billion in corresponding charges. Providers can use Experian Health's Coverage Discovery solution at any point in the revenue cycle to look for previously unidentified coverage – maximizing insurance reimbursement revenue and reducing accounts sent to collections, charity, or bad debt. Coverage Discovery also automates self-pay scrubbing and proactively identifies billable Medicare, Medicaid, and private insurance options, using a mix of search, historical information, proprietary data sources and demographic validation. See how the right data and analytics can help providers better understand their patients, streamline operations, and improve revenue.

In today's healthcare landscape, providers face the challenge of making costs transparent and understandable for consumers. The Hospital Price Transparency Rule has driven progress in this area, but there is still work to be done. In 2022, 70% of hospitals complied with the Hospital Price Transparency Rule, up from 21% in 2021, according to the Centers for Medicare & Medicaid Services. The Rule mandates hospitals to provide consumer-friendly pricing displays for more than 300 shoppable services, plus a machine-readable file with rate information. To address this challenge, healthcare organizations need to leverage price transparency solutions that empower patients throughout their financial journey. By equipping patients with advanced knowledge of treatment costs and coverage details, providers can facilitate informed healthcare decisions, expedite payments, foster patient loyalty, and gain a competitive advantage. Prevent confusion about costs with transparent healthcare pricing A recent KFF survey found that almost six in ten insured healthcare consumers have encountered problems paying for care in the last year. More than half said they found it difficult to understand their health insurance, while three in ten said their insurance paid less than expected. Confusion about coverage can lead to delays, denials and difficulties in accessing care. Two scenarios are common when patients are faced with unexpected and increasing healthcare costs: 1) they delay care until their year-end deductibles are met, or 2) they forego care completely. Neither is good for their health, and both can disrupt providers' revenue cycles. By arming patients with advanced knowledge of treatment costs and how these will be split between patients and payers, providers can help patients make informed healthcare decisions without worrying about sticker shock. And price transparency is not just a question of compliance - making healthcare billing more transparent can be a driver for growth, through expedited payments, patient loyalty and market advantage. Compassionate financial counseling, flexible financing programs, clear billing statements and simple payment options all play a role. What can providers do to improve price transparency? Step 1 in delivering price transparency is to ensure compliance with the Hospital Price Transparency Rule. Experian Health and Cleverley + Associates have partnered to help providers satisfy the requirements. Experian Health's Patient Estimates supports providers in compiling the required list of shoppable service items, while Cleverley + Associates delivers the machine-readable files quickly and at scale. Jamie Cleverley, President of Cleverley + Associates, says: “Trying to pull together all of the required information in one place led to a lot of complexity for hospitals, at a time when a lot were short-staffed. We became a natural resource for hospitals. Since we have the information and the technical capacity, we could relieve the anxiety around compliance.” Riley Matthews, Lead Product Manager at Experian Health, says the joint approach has succeeded in helping hospitals comply with both aspects of the rule: “We had a portal that we can integrate with our clients' websites, where patients are able to walk through a user experience that guides them to their price estimates. Cleverley came in with the complex machine-readable files and has been a fantastic partner from the start… We're able to solve both sides of the price transparency rule and provide a holistic solution that delivers value for our clients.” Hear Riley Matthews and Jamie Cleverley discuss how this strategic partnership will help healthcare organizations address the challenges with compliance: Utilizing healthcare price transparency solutions throughout the patient journey To round out the patient financial experience, healthcare organizations should consider proactive solutions that promote clarity and convenience at every financial touchpoint. For example: Patient Financial Advisor is the first solution in the market to provide consumers with a pre-service, mobile-estimated patient responsibility and payment experience. This allows patients to make easy, secure payments as soon as they're ready. Patients get a clear breakdown of everything they need to know about their financial obligations, delivered straight to their mobile devices. To solve for confusion around coverage, Experian Health's Coverage Discovery® solution helps patients find missing or forgotten coverage. Patients welcome their providers' help in identifying additional coverage options, so they aren't billed for costs unnecessarily. Providers can seek reimbursement through those plans, rather than sending accounts to collections. Providers can also promote clarity when it comes to payments. PatientSimple offers patients a secure, 24/7 portal to view and manage their healthcare costs in a straightforward and convenient way. Not only can they see accurate price estimates at the touch of a button, but they can also apply for charity care, set up payment plans, update payer information and make payments to multiple providers. Implementing healthcare price transparency solutions to meet regulatory requirements Creating a more transparent approach to healthcare pricing and billing can be a daunting task in the context of ongoing regulatory change and operational challenges. It's time to incorporate Experian Health's innovative solutions to navigate ongoing regulatory changes, overcome operational challenges, and enhance the financial experience for both providers and patients. Find out more about how Experian Health is helping providers comply with price transparency rules and exceed patient expectations for clear and comprehensive billing experiences.

As healthcare providers strive to deliver the highest quality care, it’s critical to understand the importance of improving the patient experience. Patient experiences can have a huge influence on overall healthcare quality and long-term outcomes. This is good news for patients, who consistently say they value healthcare encounters that surpass expectations. Research by Experian Health and PYMNTS in 2022 uncovered frictions in the patient journey, with patients commonly frustrated by poor communications, confusing and time-consuming administrative processes, and a lack of digital choices. In 2023, patients sent a clear message in response to the State of Patient Access 2023 survey: more than half of those who think patient access falls short of expectations would consider switching providers for a better experience. Creating an outstanding patient experience built on empathy, choice and personalization is therefore key to retaining loyal and happy consumers. Healthcare providers should utilize digital tools to offer timely access to services, clear and comprehensive communications, and a tailored approach to patient engagement to foster patient satisfaction – or risk losing patients to their competitors. Why the patient experience matters The patient experience is a gateway to the healthcare system. It encompasses every step the patient takes while seeking and receiving medical care. This goes beyond the clinical aspects of care and includes all the systems and strategies that determine a patient’s access to care. From the moment they book their appointment through their clinical care and final bill payments, each interaction is an opportunity to make or break a patient’s satisfaction with their provider, so improving the patient experience is crucial. The connection between patient loyalty and a provider's revenue is undeniable. However, it is important to recognize that the patient experience plays a significant role in health outcomes. Inefficient systems can lead to missed appointments, while confusing billing practices can prompt patients to postpone care. Adherence to care plans is far more likely when patients are engaged in positive, streamlined and user-friendly pathways. And when patients are positive about their healthcare experience, there are trickle-down effects for staff too, as patient frustrations are minimized and efficient processes ease workload pressures. What does a quality patient experience look like? Alex Harwitz, VP of Product, Digital Front Door, at Experian Health, says that a high-quality patient experience should encompass three things: “Choice, flexibility and convenience are themes that have come through strongly in each of our patient surveys. Patients are more mobile and more digitally active, so they expect services to be available on demand. They have a diverse range of schedules, responsibilities and preferences, and providers need to accommodate these variations so accessing care feels easy and convenient. Providers that leverage digital technology to deliver a patient-centered experience will see higher levels of patient engagement, better health outcomes, and a healthier bottom line.” Key factors affecting patient experience Clinical care: It goes without saying that the quality of clinical interactions is a major determinant of the patient experience. Unfortunately, clinical staffing shortages are putting pressure on providers, particularly in rural and low-income areas and in specialties including primary care, obstetrics, and psychiatry. More than a third of nurses say they plan to leave their jobs. Automation and digitally enabled self-service technology could help make workloads more manageable, as well as improve patient outcomes and close gaps in care. Administrative processes: The convenience of booking appointments, registering for care, and navigating billing systems can greatly impact how patients perceive the quality of their care. Efficient and accessible online scheduling, simple and transparent billing, and a choice of channels through which to access information can all play a role. Staff friendliness and availability can also affect patient perceptions. Logistical factors: If patients can’t actually get to a healthcare location easily, this will have a negative impact on their experience. Opening hours, accessible facilities, cleanliness, parking and transportation are factors to consider. How to improve the patient experience (by opening the digital front door) For healthcare providers, there’s always a new delivery challenge around the corner. But it’s also easier than ever to improve the patient experience, thanks to digital technology. Online self-scheduling allows patients to book appointments 24/7 in a convenient and flexible way. Patients can see real-time appointment availability so they can see their doctor as soon as possible, and receive automated reminders so they don’t miss their appointment. Improving the management of cancellations and rescheduled appointments leads to more efficient use of doctors' time, leading to enhanced clinical experiences for patients, too. Targeted patient outreach solutions complement this, by helping providers schedule more visits with automated text messages and interactive voice response campaigns. Patients can book appointments and make payments right from personalized messages, instead of waiting for call centers to open or having to pay through slower traditional methods. Similarly, automated registration using patient intake software and patient portals allows patients to handle pre-appointment administration more easily. Recent data from Experian Health and PYMNTS found that a third of patients choose to fill out registration forms using digital methods, while almost two-thirds would change providers to one that offers a patient portal. In addition to delivering a consumer-oriented experience, automation relies on robust data, which reduces the risk of errors on patients’ records, in turn preventing delays and confusion. Finally, offering digital price transparency and payment tools is an essential strategy to meet patients’ expectations and help them figure out better ways to pay their bills. More than 6 in 10 patients who have received an unexpected bill or inaccurate estimate would switch providers, which again points to the competitive advantage in opening the digital front door. Proactive price estimates, support to find missing coverage, and tailored payment plans make the financial journey far less stressful for patients. Patient Financial Advisor can bring these elements together and give patients the option to make online payments, boosting patient collection rates. To enhance the patient experience, it is crucial to identify the moments when patients can be provided with support and reassurance. However, the impact of this goes far beyond patient satisfaction. By focusing on improving the patient experience, a chain reaction of advantageous outcomes occurs throughout the entire healthcare ecosystem, including improved revenue. Learn more about how Experian Health's digital solutions can help healthcare organizations focus on improving the patient experience.

Millions of patients and their healthcare providers face challenges as State Medicaid agencies unwind coverage rules enacted as part of the COVID-19 public health emergency (PHE) that ended in April, 2023. The Kaiser Family Foundation estimates that 5.3 to 14.2 million people will lose Medicaid coverage as the continuous enrollment provision of the PHE ends. Meanwhile, providers may find themselves in an extended state of flux over the next year as Medicaid members have their eligibility re-evaluated and, in many cases, dropped. Kate Ankumah, Principal Product Manager, oversees  Insurance Eligibility Verification solutions at Experian Health. She shares some of the ways providers are managing new demands as they work to keep themselves—and their patients—up to date on coverage changes while navigating Medicaid redetermination and helping patients explore new financial options. Q1: When does the Medicaid redetermination process begin? “Some states have already started the Medicaid redetermination process,” Ankumah says. “Five started in April [of 2023], another 14 states started in May, and we expect many more to start in June. It's going to be a rolling process. Most states are saying this will be a 12- to 14-month effort.” Q2: What can providers expect from their state Medicaid agencies while the renewal process is happening? “State agencies will be going back through their rosters on a monthly cadence to determine who still qualifies for Medicaid,” Ankumah explains. “State Medicaids will start by using internal information to determine eligibility, whether that's eligibility for SNAP benefits or other government data they have access to. If they can't qualify members automatically, they'll reach out to members for more information. If they determine a person is no longer eligible—or they don't get information back by the deadline they've set—that member will be dropped from Medicaid coverage, possibly without ever knowing that they were supposed to respond to an email or other communication to keep their coverage.” Q3: What impact does Medicaid redetermination have on provider workflows? Ankumah sees three major areas of concern: changes to coverage, communication challenges, and downstream impacts on revenue and collections. “Providers should expect to see the hit rate for finding active Medicaid coverage to dip over the next 12 to 14 months. Normally, when reporting shows a decline in Medicaid eligibility, you might think that the payer was down or that the clearinghouse wasn't making the connection. Right now, we know that these are more likely people who don't have coverage,” Ankumah says. “I think providers can also expect to see a lot of very confused patients,” she continues. “Providers are going to need to make phone calls and have difficult conversations with patients who had no idea that this was happening and are frustrated and flustered by this change. “And then ultimately, there are going to be more self-pay patients. Many of these patients will be people who didn't know that they were at risk of losing their Medicaid coverage and aren't sure how to proceed.” Q4: Are there ways to optimize eligibility to mitigate some of the issues being created as redetermination rolls out? “One thing we're seeing is providers utilizing the batches they run through state Medicaid(s) to get a bit of a heads-up about coverage changes. If the provider's state Medicaid is dropping people from its rosters on the first and the 15th of the month, the provider might send everyone they're seeing for the first half of the month through on the first. If they find out a patient has been dropped, they have time to reach out and talk about coverage before the patient comes in for their appointment.” Dealing with the potential fallout is better with advance notice—for providers and patients. “It's a terrible patient experience to walk in thinking you have coverage and finding out you don't,” says Ankumah. “It's not the provider's fault, but patients can feel blindsided learning they'll have to pay out of pocket for care.” “Some clients are also running more frequent batches to try to get a better idea of when [during the month] their state is dropping members. Are they always dropping on the first of the month? Are they dropping on Mondays? It's a bit of an iterative process trying to understand the timing of it, but clients want to learn as soon as possible when a patient is dropped from the roster so they can reach out and have a plan before they walk in to be seen by a doctor.” Q5: Are states including redetermination dates when they send back eligibility transactions? “Some state Medicaids are indicating redetermination dates, but so far there's no standard for doing this. There's no specific field for redetermination dates in the 271,” says Ankumah. “Some states are picking a field and using it: Often they'll use the certification date, or they'll add a message segment to an open field at the end of the 271.” “As states begin to communicate if and where they are sending the redetermination dates in the 271s—and as we can verify that in our system—we can let our clients know that they can start to leverage this information to let patients know when their coverage is ending." “It may seem strange that we can't point to one field that state agencies are using to communicate redetermination dates,” Ankumah says, “but we're dealing with 50 different agencies, each doing it their own way. We're continuing to look for patterns and to work with clients to puzzle this out.” Q6: What can providers do to support patients that are being dropped from Medicaid? If providers learn that a patient has been dropped from Medicaid, Ankumah suggests directing the patient to their state Medicaid website to try re-enrollment. If their organization has a Medicaid enrollment team, they can be an excellent resource for patients. Additionally, providers may want to leverage tools that help patients navigate their financial responsibility. Finding alternative coverage: “For patients who have lost Medicare, Coverage Discovery can help find coverage that they don't know or aren't sure about,” says Ankumah. “They may have signed up for new coverage but aren't sure of their plan information and details. Or they may be covered under an employer's policy without realizing it. Coverage Discovery lets providers search for coverage with the click of a button.” Exploring coverage and payment options: “Patient Financial Clearance helps sort out which patients may qualify for Medicaid re-enrollment, presumptive charity, or—if needed—payment plans that can help manage self-pay balances." Optimizing collections: “Finally, our Collections suite of products can scan patient balances and score accounts to help providers prioritize accounts that are most likely to pay.” Q7: How is Experian Health helping individual clients deal with Medicaid redetermination? “When we talk about these issues generally, we tend to give a lot of 'it depends' answers,” says Ankumah. “That's because a lot of what's happening is state dependent. We really want to make sure that we offer guidance that gives our clients the most value and fits their individual circumstances. “With that in mind, one of the best things a client can do is to work with their relationship manager. They can offer real insights into how their state Medicaid is addressing redetermination, including dates and timing.” Relationship managers can also help providers navigate workflow changes efficiently. “For example, a provider might think sending through daily batches to see who qualifies for Medicaid is a good idea, but they'll be charged for those transactions and can very quickly go over their budget. Our team is here to help providers develop protocols that keep them up to date without overdoing it. “We also have a team dedicated to monitoring payer updates,” Ankumah notes. “We're following what our clients are hearing from their state Medicaid agencies, but we're also looking closely at updates and querying our databases to leverage information and return it back for the benefit of all our clients.” Find out how Experian Health's Insurance Eligibility Verification solution can help connect providers with more than 890 payers, including state Medicaid agencies nationwide. 

“With Coverage Discovery, Luminis Health can now find more billable coverage, whether primary, secondary, Medicare or Medicaid. Luminis can follow up immediately with payers when there is no initial real-time eligibility response available. Not only does this improve financial performance, but it also reduces manual work and minimizes errors before claims are filed.” Sheldon Pink, Vice President of Revenue Cycle at Luminis Health Challenge Luminis Health is a not-for-profit health system with an annual revenue of $1.2 billion and over 9000 employees. As one of the top three hospitals in Maryland (according to the U. S. News and World Report), Luminis’ vision is to break down barriers to health and deliver more high-quality care across the region. Finding and verifying insurance coverage for more self-pay patients was contributing to Luminis Health’s levels of bad debt. Staff relied on manual processes that were time-consuming and inefficient, and a vendor solution that did not integrate with Epic®. Limited productivity led to delays, denials and compromised patient experiences. To resolve these challenges, the organization’s goals were to: Create a positive patient financial experience by providing accurate and quick patient financial estimates Reduce bad debt by finding accurate primary and secondary insurance coverage Eliminate manual processes for following up real-time eligibility (RTE) responses with payers Reduce the number of self-pay patient accounts that end up in bad debt Solution With Coverage Discovery, Luminis was able to maximize reimbursement, reduce bad debt and improve the patient experience. Coverage Discovery finds additional active coverage that patients may have forgotten about. Using verified patient information, proprietary databases and confidence scoring, the tool scans for active coverage across the entire patient journey. This means no financial stone is left unturned before the patient is billed directly. By identifying coverage that would otherwise have been missed, Luminis can avoid misclassifying patients as self-pay, and prevent accounts from being incorrectly sent to bad debt or charity. Staff can focus on accounts most likely to be rebillable to insurance, rather than wasting time on avoidable manual rework. In certain instances when patients do not know they have secondary coverage, Coverage Discovery: Verifies patient demographics to ensure patient details are correct Leverages a range of proprietary databases (including Employer Group mapping) and historical patient search information to find insurance that may have been used and verified at other locations Applies a confidence scoring system to reduce the noise and eliminate “false positives,” so the client doesn’t waste time reviewing incorrect information or irrelevant coverage Outcome As a result of using Coverage Discovery, Luminis found more than $240k in active coverage on average per month in 2021. They reduced the number of self-pay patient accounts ending up in bad debt and created positive patient financial experiences by minimizing patients’ financial obligations. Reducing reliance on manual processes also led to fewer real-time eligibility responses from payers. Sheldon Pink reports that implementation was straightforward, thanks to Coverage Discovery integrating seamlessly with Epic® and support from the Experian Health team: “We’re impressed with these results and with the partnership with Experian Health. Luminis is looking forward to building on this success and continuing to collaborate with the Experian Health team.” Find out more about how Coverage Discovery helps healthcare organizations find missing and forgotten coverage, to improve financial performance and contribute to a better patient experience.

U.S. hospitals have been stuck with more than $745 billion in uncompensated care costs for the past 2 decades, and the number continues to grow.  Other factors like patients relocating, changing employers, and coverage renewals make recovering debt even harder. The recent end in COVID-19 funding has also made it more important than ever for healthcare providers to find missing insurance coverage. Finding insurance coverage can be complicated and time-consuming, especially in an already complex reimbursement landscape. However, it doesn't have to be. That's where Coverage Discovery comes in. Coverage Discovery is the only comprehensive coverage identification solution across the full revenue cycle continuum. It covers the entire patient process and uses multiple proprietary data repositories, advanced search heuristics, and machine learning matching algorithms to search government and commercial payers to find previously unknown insurance coverage. This includes identifying accounts that may be submitted for immediate payment as primary, secondary or tertiary coverages. This automated coverage identification solution can search for unidentified coverage pre-service, at the point of care, and post-service. It also scans for insurance coverage continuously - to maximize reimbursements and minimize accounts sent to collections and to charity.  In 2022, Coverage Discovery tracked down previously unknown billable coverage in more than 28.1% of self-pay accounts and found more than $64.6 billion in corresponding charges. Learn more about this solution: It's time to reduce bad debt and improve cash flow. Identifying hidden insurance coverage is the first step to managing insurance denials and your organization’s healthcare financial performance. A solution like Coverage Discovery can help healthcare organizations save time, money and alleviate staffing shortages. To learn more about how Coverage Discovery can benefit your healthcare organization, contact us.

With inflation still high, the economic outlook remains uncertain for healthcare consumers. Many households feel squeezed by rising housing, food and fuel bills, while their incomes remain broadly static. Inflation’s impact on healthcare can be seen in delayed treatments, as a 2022 Gallup poll found that 38% of patients postponed medical care because of concerns about costs – the highest amount since the poll began in 2001. The situation is exacerbated by the fact that Medicaid continuous enrollment came to an end on March 31, 2023. To complicate things further, reimbursement rates and employer health plans tend to be negotiated in advance, which means inflation can take longer to filter through the healthcare economy. Both McKinsey and Deloitte predict that hospital profit margins will reduce in the coming year or so. Resulting price increases will be reflected in employer coverage plans, and ultimately pass to workers in the form of higher deductibles and out-of-pocket costs. In short, inflation’s impact on healthcare may continue to create ripples in the healthcare industry. For healthcare providers, reimbursement may become more challenging as patients find it harder to pay their portion of the cost. What can providers do to mitigate inflation's impact on healthcare? Providers are already working to maximize operational efficiency with automation and digital tools that reduce workforce pressures, streamline back-office processes, and leverage data to drive improvements. Reducing costs is just one side of the coin. The other is to maximize opportunities for reimbursement by supporting patients throughout their financial journey and making it as easy as possible for them to pay. Here are 4 ways that healthcare providers can mitigate inflation’s impact on healthcare while reducing friction for patients and maintaining cash flow: 1. Provide transparent pricing and upfront patient estimates Because inflation has forced patients to prioritize their spending, many are opting to postpone healthcare. But delaying treatment or stretching out medicines to save money could lead to poorer health outcomes, and potentially more expensive treatment being needed later. By proactively offering patients accurate pricing estimates before they come in for care, providers can help patients get a fuller picture of what their final bills are likely to be. Estimates can be sent directly to the patient’s mobile device, along with user-friendly links to payment plans and payment methods. This makes it much easier for patients to plan, so they’re less likely to default on payments or delay care. 2. Help patients find unknown insurance coverage With the end of continuous Medicaid enrollment, millions of patients could have gaps in coverage. While this is largely an issue for states to manage, providers can take steps to help patients find additional coverage, and support those at greatest risk to find financial assistance and plan for upcoming bills. Coverage Discovery can be used at any point in the revenue cycle to search for missing or forgotten billable coverage. It uses advanced search and proprietary data sources to check for both government and commercial insurance coverage. When coverage is found, patients get the reassurance of knowing that their bills will be covered, while providers can avoid writing off these accounts to bad debt. And because Coverage Discovery uses a contingency fee pricing model, providers only pay for the tool when they are reimbursed. 3. Offer simple and convenient methods to plan and manage bills Prescription medications, inpatient visits and other services are expected to increase in price over the coming year. Americans may be more concerned about how they’ll shoulder the costs – especially the 49% who say they’d be unable to pay an unexpected bill of $1000 or more. Providers can make the process easier for patients with data-driven digital tools. Patient Financial Clearance identifies patients that are likely to be able to pay upfront and those who may need a payment plan or financial assistance. This information allows providers to engage in compassionate financial counseling to make sure patients are guided to the most appropriate pathway. Another option is to leverage self-service tools to give patients more control over how and when they pay. Patient Financial Advisor offers pre-service estimates and payment options that patients can access anywhere, anytime. They can take stock of their financial situation, plan for bills, and then make payments at the click of a button. If it’s easier to pay, patients will be less likely to delay. 4. Make it easier for patients to schedule care While many patients may consider delaying care because of cost, many say they’ve postponed treatment for other reasons. Concerns about COVID-19, work commitments, and difficulty booking appointments can also lead to delayed care. For those that are foregoing care for reasons other than cost, providers should look at improving the patient access experience with more self-service options. Online self-scheduling allows patients to book, reschedule and cancel appointments at their own convenience. Digital patient registration similarly reduces friction, by enabling patients to fill out forms from their mobile devices. Patients will be less likely to forego care when access is as easy as ordering groceries online. Proactively reducing inflation's impact on healthcare Inflation’s impact on healthcare continues to be felt – and could get worse as the year goes on. Rising medical bills may cause patients to keep deferring care. Providers can proactively reduce the effects by incorporating digital solutions and patient engagement strategies that make it easier for patients to afford and receive care. Find out more about how Experian Health can help healthcare organizations bolster their revenue cycles and mitigate inflation’s impact on healthcare.

Because so many healthcare claim denials originate in the front end of the revenue cycle, providers should focus on improving insurance eligibility verification at the early stages of the patient journey. Verifying coverage earlier in the billing process with automated eligibility verification software increases the chance of submitting clean claims the first time and protecting future revenue. As coverage and benefits become more challenging for patients to navigate, prioritizing eligibility could also hold the key to better patient-provider relationships. Given the complexity of the healthcare billing system, patients have little tolerance for errors and delays. Many already worry about being able to cover their financial obligations, so denied claims are the last thing they want to see. Insurance verification reduces denials, gives patients greater clarity over their upcoming expenses and allows healthcare organizations to focus on providing the best possible care. This article looks at why improving insurance eligibility verification can help healthcare providers optimize cash flow and achieve higher levels of patient satisfaction and loyalty. What are the steps in the insurance eligibility verification process? Before filling out a claim, providers must be sure that the services they’re seeking reimbursement for are covered by the patient’s health insurance. They must also check that the patient’s details match those on their insurance plan. If a provider offers treatment or services and it later turns out that the patient’s coverage has expired or the patient is ineligible for those items, the claim will be rejected. To verify eligibility, providers must therefore be able to answer the following questions: Are the patient’s contact details current and correct? Does the patient’s insurance plan cover the planned treatment or services? Do any exclusions apply under the patient’s plan? Have all necessary pre-authorizations been obtained? Is the coverage active? What are the thresholds for deductibles, co-pays or coinsurance, and do any annual or lifetime limits apply? Confirming eligibility early on lays the groundwork for better claims management and minimizes the chance of errors. How does an effective eligibility verification system benefit patients and providers? Accurate and timely insurance verification clarifies to all parties how bills will be covered (or not) ahead of time. If a claim ends up being rejected, the patient will find themselves with responsibility for more of the bill, the provider will be left uncompensated for services rendered – or both. Clarifying coverage in advance avoids these scenarios. When providers can generate and communicate pre-service patient estimates with confidence, patients can plan for their bills and even make payments before or at the time of service. The financial benefits are clear, but patient satisfaction is also likely to increase: a study by Experian Health and PYMNTS found that patients who received pre-treatment estimates were more satisfied with their care than those who did not. Automated pre-service eligibility checks also improve communication between patients, providers and payers by reducing the manual workload on staff. Instead of spending time checking and fixing errors, staff can focus on helping patients with more complex cases. According to the CAQH, as much as $10 billion could be saved each year by switching to electronic eligibility and benefits verification. How does it help the claims process? In Experian Health’s report on the State of Claims 2022, the most common reasons given for claims being denied included: issues with prior authorizations, provider eligibility, patient information, changing payer policies and services not being covered. Automated eligibility verification helps solve each of these. With fewer errors in the pipeline, organizations can file claims faster and receive payments in a timelier manner. Eligibility Verification accesses up-to-date eligibility and benefits data from multiple sources, generating an instant read-out of a patient’s insurance status. More accurate information increases clean claims rates, accelerates reimbursement and allows providers to forecast future revenue levels more reliably. Staff can view responses in a clear and concise format and receive alerts when follow-ups or edits are required. This sets the tone for a more efficient claims process all around. Proactive and error-free claims management saves staff time that might otherwise be spent on reworking claims and engaging in lengthy disputes with payers. From the patient's perspective, earlier verification can fast-track registration because much of their information is checked before they even arrive for care. Waiting time is reduced because staff benefit from more streamlined workflows. As noted, finding missing coverage gives patients clarity over what they owe, so they’re more apt to pay bills on time. Automation can also be used to connect patients to the appropriate financial support. For example, with Patient Financial Clearance, providers can offer compassionate financial counseling and get patients on the right financial pathway. It improves the patient experience while reducing the risk of bad debt. What does a good insurance eligibility verification system look like? When it comes to choosing an insurance eligibility verification solution, the checklist should include the following features: Compatibility with existing systems and electronic health records - Eligibility Verification accelerates verification and registration by drawing together accurate patient data. And through eCare NEXT®, clients can manage multiple patient access functions through a single interface. Simple methods for updating or changing patient information - User-friendly interfaces allow staff to make changes from any device, as and when new information arises. Integration with patient portals means patients can spot errors themselves, too. And tools such as Registration QA can drive data accuracy by highlighting errors as soon as they occur, both pre-and at the point of service. Rapid results, with patient benefits information readily available when needed - Eligibility Verification confirms patient eligibility and calculates reimbursement estimates with precision. This incorporates CAQH COB Smart® data for enhanced coordination of benefits in relevant transactions. Ability to calculate patient estimates - A verification tool that integrates with automated patient payment estimates ensures patients understand their coverage, co-pays and deductibles before treatment proceeds so that they can plan for their final bills. Integration with pre-authorization tools - For some services, a payer may require the provider to seek authorization before going ahead. An insurance verification solution can flag up where prior authorization is needed to prompt action and prevent delays. Ability to source data from major health insurance carriers, including Medicare - Eligibility Verification connects with nearly 900 payers with advanced search functionality to match patients to current eligibility and benefits data. This can be used alongside an optional lookup service for Medicare beneficiaries to find and validate MBI numbers. Ongoing changes to the health insurance landscape mean that providers must pay close attention to the process of verifying coverage and benefits. Although insurance verification is a small step in patient access, the impact can be felt throughout the patient’s journey and the provider’s revenue cycle. By optimizing for earlier and more accurate insurance verification with workflow automation and advanced data analytics, providers can reduce the risk of denied claims, improve financial performance and protect patient-provider relationships. Find out more about how Experian Health can help healthcare providers streamline their claims process with front-end improvements to verify insurance eligibility, file error-free claims and get paid faster.

On April 1, 2023, millions of Medicaid recipients are set to lose coverage as the U.S. government’s COVID-19 public health emergency (PHE) expires. The Kaiser Family Foundation estimates that 5.3 to 14.2 million people will lose Medicaid coverage as the continuous enrollment provision of the PHE ends. Of this group, 6.8 million may be eligible to re-apply for Medicaid, but in the immediate term, it falls to patients and providers to sort through coverage questions, navigate charity and Medicaid eligibility, and keep bills out of collections. Mindy Pankoke, Senior Product Manager at Experian Health, shares her insights on how Patient Financial Clearance and other digital solutions can help providers and patients cut through the confusion to achieve the best healthcare and financial outcomes during this time. Q1: The public health emergency is ending on April 1, which means that many will lose Medicaid coverage. How will this impact providers and patients? “Patients who qualified for Medicaid under the Public Health Emergency requirements during COVID will be dropped from Medicaid on April 1, leaving them without coverage,” explains Pankoke. “Healthcare organizations have been trying to reach out proactively to pre-enroll some of these patients, but others may not know what their options are or may show up to receive care without realizing they no longer have coverage.” Patients will face a range of financial challenges. “Self-pay patients may defer treatment, which could keep them from receiving the care they need and may ultimately lead to more costly hospital visits,” Pankoke says. “Also, patients may be confused about what’s happened to their coverage and what their options might be going forward. If they end up being responsible for paying out of pocket for care, some may have to choose between paying their medical bills and paying for food or utilities.” Providers will see a surge in patients needing help after losing Medicaid coverage With millions of patients in flux, providers will need to dedicate time and attention to helping patients sort through their concerns, including: Confirming whether Medicaid coverage is still in force Verifying coverage with new insurance Determining eligibility to re-enroll in Medicaid Qualifying patients for full or partial charity care Explaining patient financial responsibility and working out payment plans Managing billing and collections with a higher volume of accounts in AR Optimizing outcomes so that patients get the best care possible and providers end up with the least amount of bad debt Time is a critical element. Lengthy processes and administrative delays are likely to increase patient stress levels. Meanwhile, many providers face industry-wide staffing shortages. Time-consuming manual processes, multiplied by a sudden surge of affected patients, could quickly become overwhelming for staff. “For providers, this could be a hard situation to navigate,” says Pankoke. “At the same time, it gives providers an opportunity to come through for patients in a moment of need. Being able to identify patients who need assistance and offering them help can be powerful.” Q2: That raises an important question: How can providers create a compassionate experience for patients? “I think awareness is one place to start: making sure your staff knows this change is coming and that they understand the impact,” Pankoke says. “Your staff are the ones who’ll be working with patients personally when they come in and find out they no longer have Medicaid coverage.” But compassion doesn’t end there. “Many providers already have charity programs in place to provide relief for patients who can’t afford care,” says Pankoke. “The challenge lies in identifying the patients who need that charity assistance and connecting them to the help that’s available, while also learning which patients may still qualify for Medicaid and need help to re-enroll. Patient Financial Clearance uses credit and non-credit data to identify patients who may still be eligible for Medicaid, as well as self-pay patients who may qualify for charity assistance.” Using data-driven digital tools to quickly and proactively size up patient financial needs and offer personalized help can make the patient experience more humane. “Making these steps easier is another piece of being compassionate.” Q3: Screening for charity can be complicated, especially when new regulations are introduced – how do providers streamline this process? “My best advice is to embrace your charity programs and use a partner like Experian Health to help you automate the financial assistance screening process,” says Pankoke. “Patient Financial Clearance removes the manual screening for the likelihood to qualify for your charity programs and Medicaid.  It can automate the document-gathering in a patient-friendly way, and speed up the process to extend charity assistance, or work to enroll those likely to qualify for Medicaid early on before patients go through a costly uncollectable experience.” Automating these processes doesn’t have to be onerous. “Clients can provide their charity policy  requirements to Experian Health and let our expert consultants help to create the most effective and efficient workflows for Medicaid and charity screening both  up-front and as back-end scrubs.” Pankoke also urges providers to consider patient self-screening options as well: “Providers should consider other options aside from paper applications.  We’ve seen clients shrink the application process from 60 days of paperwork down to 3.5 days by enabling patient self-screening options via text.  This creates a better experience for the patient and hospital staff.” Q4: What else can providers do to help patients manage the cost of care? Providers can focus their resources on improving the patient's financial journey—for all patients, not just those who are struggling with their Medicaid status. Pankoke’s suggestions: Reach patients on their preferred channels - “Providers can empower patients with less paper-heavy ways to apply for financial assistance. Text and online applications embedded on your website or patient portal put the power into the patient’s hands using the channels they prefer.” Providers can also offer patients the ability to make payments right from their mobile devices using Patient Financial Advisor, making it easier to pay outstanding bills anytime and anywhere. Use data to gain insight into patient finances and offer personalized options - “In addition to screening for possible charity and Medicaid eligibility, Experian data enables providers to offer realistic payment plan options that consider how much the patient is likely to afford, enabling patients to bite off what they can chew with higher likelihoods of making payments successfully.” Customize collections - Sending patients who are struggling to collections may not be cost-effective or compassionate. “Providers don’t want to hound people for payment if the patient is having trouble covering their basic expenses and could qualify for Medicaid or charity care,” says Pankoke. Using Collections Optimization Manager, providers can tailor collections processes to their own specific needs. “A partner who is agnostic to your in-house and early-out agencies can help you manage, monitor, and optimize agency performance for maximum revenue.” Providers who are concerned about upcoming shifts to Medicaid coverage may want to consider leveraging solutions like Patient Financial Clearance, Collections Optimization Manager and Patient Financial Advisor to help them meet this challenge—along with the many challenges of managing patient financial needs in a rapidly-changing world.