OverviewIntake, Benefits &

AuthorizationsPrepared and Presented by

Mae Regaladoand

Linda Hagen

Objectives

1. Discuss the nature and importance of effective patient intake and front-desk procedures at the time of patient check-in.

2. Review benefit authorization processes and their relevance to billing.

3. Review patient check-out and co-insurance collections.

Intake Process

• A functional billing system begins with having an efficient and effective patient intake process, as well as with tracking each patient's information throughout each encounter.

• This ensures that patients receive the services they need and that they're billed appropriately for those services.

• Evaluating a provider’s entire process, from patient check-in through treatment services and follow-up, is extremely important to establishing and maintaining an efficient system.

Intake: Basic Principles• The following basic principles should help as you assess

your own intake and charge-capture process.– A smooth patient check-in is essential to meeting the needs of

each patient in an orderly fashion. – Front-desk staff members need to initiate a patient charge sheet

(which also may be called an inpatient encounter form or outpatient encounter form) for each patient.

– The patient's insurance policy and policy number should be listed on the form.

– If the patient has health insurance. A copy of the patient charge sheet is then attached to each patient's medical record.

– The patient charge sheet should follow each patient through his or her office visit.

Patient Check-out and Billing

• Before the patient leaves the office, staff uses the patient charge sheet to gather any additional information needed and make any arrangements needed.

• This could include processing a referral to a specialist or even making preparations for admitting the patient to a hospital.

Billing Process

In order for the billing process to be effective, providers must pay attention to:

• Insurance Coverage• Benefits Verification• Eligibility Verification• Authorization Verification• Co-pay collection

Eligibility Verification

• It is more important than ever to check on the insurance eligibility of every patient.

• According to industry sources, 75% of all healthcare claim denials are because a patient is not eligible for services billed to the insurer by the provider. Often, a patient would be ineligible for benefits because his or her policy has been terminated or modified.

• Patients switch plans more frequently than they used to, and they are bearing more of the cost of healthcare.

More on Eligibility Verification

• Over the course of treatment, as patient balances tend to grow due to higher co-pays and/or coinsurance, it is critical to focus on reducing those balances

• There are several ways to check eligibility, but the old-fashioned method of going through health-plan rosters line by line is labor-intensive, and the lists are often inaccurate.

• Calling the plan on the phone usually takes too much time, unless a voice response system is available.

More on Eligibility• Many health plans allow practices to check eligibility

online, and some enable them to do that with swipe-card terminals.

• Insurers such as United Healthcare offer “real-time claims adjudication,” so practices can instantly find out what the patient owes out-of-pocket before he/she leaves the office.

• Providers dramatically reduce accounts receivable and increase revenue, by significantly reducing the impact of ineligibility, and increasing the number of "clean" claims that are sent to health plans insurers (a clean claim is complete, accurate and for patients who are eligible for benefits).

More on Eligibility

Why Eligibility Verification Matters…

• Unfortunately, eligibility verification is one of the most neglected elements in the billing process.

• In the absence of proper eligibility and benefit verification countless downstream problems are created: delayed payments, rework, decreased patient satisfaction, increased errors, and nonpayment.

Authorizations

• Health care precertification, also known as prior authorization, is an essential component of comprehensive utilization review.

• A Prior Authorization or Authorization is a process of reviewing certain medical, surgical and behavioral health services to ensure medical necessity and appropriateness of care prior to services being rendered.

• Most health plans require prior authorization for specific services.

More on Authorizations

• Health plan insurers typically provide outlined authorization requirements and guidelines.

• If the services meet the required criteria, health plans will assign a prior authorization number and send the provider/practice a letter that includes the number.

• Be sure to include the prior authorization number with your claim for proper reimbursement.   

More on Authorizations• If a provider wants to render additional services beyond

what is covered by the initial authorization, the provider must notify the health plan and typically a new authorization number will be issued.

• A new authorization would also be needed if the provider wants to make any changes to the patient treatment, such as extending dates of service.  

• Be sure to understand exclusions and limitations. Some services that do not require prior authorization may have limitations in coverage or be excluded under the health plan program.  

More on Authorizations• Prior authorization requirements are subject to

change as a result of annual benefit modifications and/or during annual prior authorization requirement reviews.

• Most health plans’ prior authorization requirements are reviewed annually to evaluate medical and behavioral health care trends and better control health care costs for the government. 

Benefits: Co-pay Collections• Keen attention to co-pay collections has become more

critical as employers and insurance companies pass more of the cost of care on to patients.

• Patients now face higher deductibles, larger co-pays, and more shared expense for procedures and testing.

• It is a good time to look at how your organization handles patient finances and implement strategies to address these changing trends.

• This is especially true for providers accustomed to treating the indigent.

More on Benefits• Staff should obtain a patient’s co-pay when checking

his/her eligibility (Note: The amount on the insurance card is not always correct).

• Practices should also try to collect the co-pay before the patient leaves. Otherwise, you could spend more on collecting the co-pay than you receive.

• Co-pays can add up: If your average patient has a $20 co-pay and you see 30 patients a day, that’s $600; plenty of no-frills plans now require much higher co-pay and deductible levels.

• Also, check the patient’s balance before he heads for the door.

Pulling it all Together

• Even with the right software, patient billing is a challenge requiring many vital steps and a coordinated effort by medical office staff and physicians.

• Someone in the practice needs to oversee the process (intake, benefits and authorizations), keep track of reports, and make sure that billing statements and collection letters are mailed on time.

• When the details of the process get the right attention, your office and its patients can expect accurate billing, which is an important component of a well-run office and healthy patient relations.

Thank You! Questions?

Mae Regalado and Linda HagenSenior Consultants

888-898-3280www.ahpnet.comwww.behavioralhealthtoday.com