Getting the Right Eligibility Information for Payment Your Rights and Health Plans Requirement

September 11th, 2018 - BC Advantage
Categories:   Insurance   Practice Management   Reimbursement  

We need timely and accurate patient information to bill health plans and receive appropriate payment. Clinical information is, of course, important. But we also need the "administrative" data - patient demographics and especially the insurance information. Physician offices create their clinical information, but usually rely on patients for information on their health plan and identification numbers.

Just as we have standardized electronic claims transactions and remittance advice transactions under HIPAA, there are standardized electronic eligibility inquiry and response transactions which can (and should) be used by physician offices to communicate with health plans. HIPAA regulation require that all health plans make these electronic eligibility transactions available to providers. And relatively recent regulations (45 CFR 162.1203) have greatly expanded the content that must be provided in those transactions. This section of the regulations adopted, as standards, the Phase II CORE 260: Eligibility & Benefits Data Content (270/271) Rule, version 2.1.0, March 2011

(https://www.caqh.org/sites/default/files/core/phase-ii/policy-rules/260-v5010.pdf)

These rules require that all health plans (including Medicare and Medicaid) must provide real-time (i.e. almost instantaneous) responses to eligibility information. The rules also expanded the information which must be provided in all responses. Health plans must now include, in addition to the membership status and beginning and end dates:

  • Whether or not the patient is eligible for a large number of specific service types such as surgical, DME, hospital inpatient, hospital outpatient, dialysis, etc. as well as if the coverage in in network only
  • Patient financial responsibility for base and remaining deductible, co-insurance and co-payment for each service type requested.

Providers can now request and receive all of this information from health plans on a real time basis. How should this be included in your workflow?

First, make sure that your practice management system or clearinghouse gives you the capability to do these real time eligibility transactions. There are still some systems that do not support the robust information which must be provided.

If your vendor doesn't support the transaction, find out if you can get it added to your system. If not, you may wish to investigate alternatives.

If you do have the capability, it's time to put it to good use. The health plan eligibility status and financial standing for each patient should be available to front office staff before the patient walks in the door. I would recommend that near the end of the day, eligibility inquiries be sent for all patients expected to be seen the next day. Responses can be noted, and patient insurance information updated. If your office's insurance information is no longer accurate for the patient, the patient can be called and asked for updated information or to bring their updated insurance card into the office. As the patient arrives, you can update any information as needed, discuss the deductible and coinsurance with the patient, and make the financial arrangements. For any walk-in patients, an eligibility inquiry should be done upon arrival, insurance information verified, and financial arrangements made. The eligibility inquiry and response should take only seconds. Even if the patient has what they say is a current membership card, an inquiry should still be done.

Every health plan is required to have this detailed, real-time eligibility inquiry and response process. This is based on the standard transaction required under HIPAA. While health plans may, at their option, also offer Web portals with this information, they cannot force you or provide any incentive to use the portal as opposed to using the standard transaction. Using the standard for all health plans should be easier than going to each health plan's portal, logging in, and finding the appropriate information. Should any health plan tell you that you must use the portal, remind them of their obligations. There is a process in place to force health plans to comply with HIPAA rules; that can be instituted - and may be the subject of a future column.

Remember - claims are easily denied if the insurance information is incorrect. And with the rapid changes in the health care industry and patients switching health plans, you need the right information. Using the eligibility inquiry process will get you that.


This Week's Audit Tip Written By:

Stanley Nachimson,

Principal, Nachimson Advisors LLC

Stanley Nachimson is principal of Nachimson Advisors, a health IT consulting firm dedicated to finding innovative uses for health information technology and encouraging its adoption.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....
Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?
October 10th, 2023 - Aimee Wilcox
When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association