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Errors In Your Eligibility and Benefits Verification

by [email protected]

The dental billing revenue cycle is a challenging but essential procedure for a consistent and steady revenue stream. It is one of the first steps in the revenue cycle management process; which means that any mistakes or errors made at this level can lead to complications and have a significant impact on the entire revenue cycle. Inaccurate insurance eligibility and benefits verification can lead to delayed payments, denied claims and even nonpayment. 

Errors made during this process can cost your practice more money than you might think. Most claim denials occur, directly or indirectly, due to insufficient or inaccurate information gathered, which is, basically, eligibility and benefits verification. The first step to reducing the number of claim denials is to establish an efficient eligibility and benefits verification process. 

Here are some of the common eligibility and verification errors:

Inaccurate patient information

Verification is done to guarantee that your patients receive accurate billing for the services rendered. At times, errors can occur at this step; one of the most common errors being inaccurate patient information. This may happen for a lot of reasons, including a mix-up in the patient’s dental records. Something as simple as a middle name not being mentioned can lead to denials. Avoiding this problem will require that information is gathered diligently. Patients and the insurance providers must be contacted directly in case additional information is required. This also ensures that the data gathered is up to date.

Inactive insurance policy

Inactive insurance policies could be another reason for claim denials. In their hurry to submit claims, a lot of practices fail to check if the policies were active during the date of service. Information like the address for the submission of claims become invalid if the plan itself has become inactive. Contacting the insurer prior to providing the service is the best way to ensure that claims are not billed to inactive policies. Remember to verify the patient’s eligibility at the time of the visit before performing the treatment to make sure that the policy you are billing on is current. 

Failure to properly check the coverage

Eligibility and Verifications is not a process that should be done once in a year. There could be several changes that are made on policies by insurers within a plan year. Practices often make the common mistake of not properly checking the insurance coverage of their patients. This again happens for a lot of reasons, but is often due to incorrect or outdated information. This could also lead to frustrated patients, as they would have to pay out of their pockets. It is always better to contact the insurance provider and get confirmation in case there are any doubts about patient coverage. It is also important to keep up with the changes to insurance plans. If a patient has a new plan or their coverage has changed, be sure to verify that the coverage for the services provided is still in place. 

Duplicate data

Another common mistake that practices make in eligibility and benefits verification is to duplicate data entry. Duplicate data can lead to delays in billing and payment, and can also cause confusion for both patients and your staff. This may seem like a simple mistake but it can happen very easily, leading to claim denials. When entering patient information into the system, make sure to check for duplicates and correct them before moving on.

Missing documentation

A claim that doesn’t have the necessary documentation would most probably get rejected. The only way to rectify this situation would be to resubmit the claim with the proper and complete documentation. This can delay payment collection and make your patients irritated and frustrated. Information regarding documentation for each procedure needs to be collected during the eligibility and verifications process in order to avoid this problem. 

Neglecting to ask about a secondary policy

Some patients may have more than one active dental insurance plan. They are usually identified as the primary and the secondary plans. In such cases, claims should be billed initially to the primary insurance provider. Claims could get denied if the claim is billed to the secondary insurance provider. The practice staff must inquire about any secondary coverage during their eligibility checks to guarantee accurate claim filing. 

Remember, eligibility and benefits verification errors can cost your practice a lot of money. There are simple things you can do to help reduce the number of errors on your claims. Firstly, make sure that you identify and understand the eligibility and benefit requirements for the services provided to each patient. Secondly, verify that the patient’s policy meets the requirements before you provide the treatment. This can help your practice reduce the number of errors on your claims and save money in the long run.

Preauthorization In Revenue Cycle Management

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Pre-authorization is permission from an insurance company that is required before a patient can receive a certain type of treatment, care, or service. Virtually every payer requires pre-authorization for physical, occupational, and speech therapy. In most cases, if pre-authorization is not secured, services will not be covered by insurance. Most often, either the provider or the patient will be stuck with the bill for the entire cost of care.

Preauthorization refers to the practice of acquiring approval from insurers in advance for certain treatments and procedures in order to receive a possible reimbursement for those services. In other words, it is permission from an insurance company that is required before a patient can receive a certain type of treatment, care, or service. Virtually every payer requires pre-authorization for physical, occupational, and speech therapy. In most cases, if pre-authorization is not secured, services will not be covered by insurance. Most often, either the provider or the patient will be stuck with the bill for the entire cost of care. However, a majority of healthcare professionals feel that prior authorizations are time-consuming and interfere with patient treatment. The crux of the matter is that though pre-authorization does not guarantee reimbursement, the absence of pre-authorization can surely result in claim denials or non-reimbursement. Once you acquire pre-authorization from a payer, you will get a pre-authorization number. This number must be included in your claims to avoid unnecessary denials. If your claims are denied based on the lack of medical necessity, you should append this pre-authorization number while preparing an appeal letter.

To answer the most important question,

“How does preauthorization help your practice?”

  • Preauthorization in medical billing helps healthcare organizations collect the proper payment for services rendered, reduce rejections and follow up on rejected claims.
  • Preauthorization is a part of insurance verification and therefore, helps ensure that the insurance details of patients are valid.
  • Preauthorization is a way to ensure that the payer will pay the reimbursement amount without much delay.
  • Preauthorization aids in the verification of insurance details and helps to curb insurance fraud by removing erroneous insurance claims.
  • Preauthorization helps to avoid denials by obtaining payment approval from the insurance provider prior to providing the services.
  • Preauthorization allows insurance providers to assess whether a patient’s condition warrants further dental care or treatment.

Preauthorization is not as easy as it seems; there are many challenges involved. These challenges include:

Time-consuming

Preauthorizations consume so much time that they become an added burden on your staff. To successfully complete preauthorization, a lot of steps need to be followed. They include filling out request forms and submitting it to the insurance providers. A lot of time goes into the collection and verification of all the information required to process a prior authorization request. Not having a pre authorization can lead to patients not getting their treatments and creating some discord at your practice.

Complexities in preauthorization

Preauthorization in revenue cycle management can be much more complex than perceived. It can be a tumultuous task for your practice to keep up with the constantly changing policies and codes. As a result, your practice would be compromised if these changes are not implemented swiftly or there may have occurred unnecessary preauthorization in revenue cycle management  submissions.

Lack of transparency

Lack of communication between the practice and the insurance providers regarding the status of the preauthorization request can result in delays and costly back-and-forths between them. Lack of transparency can lead to a lot of confusion, which results in another set of discomfort at your practice. Therefore, it is important to have proper transparency between the practice and the insurance provider.

Some standards for prior authorization have been set. So, get to know some of the best practices:

  • The use of prior authorization related to emergency care is prohibited by the Affordable Care act.
  • There is a move to ban prior authorization for certain behavioral health care by some states in the United States of America.
  • The law in some states requires the use of standardized prior authorization methods and new transparency reporting.
  • The use of gold card laws that requires health plans to waive prior authorization for services ordered by providers with a track record of prior authorization approval has been adopted by some states in the US, while other states are considering doing the same.

Application request for preauthorization

Ensure the completed form with your request for preauthorization is bereft of any errors. Errors in your application requesting preauthorization would inevitably lead to your request being rejected. 

Submit all relevant documents on time

While submitting your preauthorization request, remember to submit all the supporting documents within the given timeframe.

Adhere to the guidelines

Preauthorization is dependent on many factors. Of these, medical necessity takes credence. Remember, not all procedures or treatments require preauthorization.

For example:

  • If a patient has had a medical emergency or needs emergency treatment, (it is not required) obtaining a preauthorization is not a requirement since it may take 5 to 10 days for the insurance provider to respond to your preauthorization request.
  • There has been a move to ban prior authorization for certain behavioral health care by some states in the United States of America.
  • The law in some states requires the use of standardized prior authorization methods and new transparency reporting.
  • The use of “gold card” laws that requires health plans to waive prior authorization for services ordered by providers with a track record of prior authorization approval has been adopted by some states in the US, while other states are considering doing the same.

Is staff replacement really a problem in RCM?

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“Will partnering with a revenue cycle management  service provider affect staff employment?” 

Or

 “Will it lead to the staff losing their job?”.

When choosing an RCM Service Provider, the practice or its employees frequently ask the following questions. It may also be a few of the typical explanations for why most businesses refrain from opting for a third party.

But are these worries really valid?

Definitely not…these are just common misconceptions or myths that exist among people, and have no proven database. Partnering with an RCM provider does not affect your staff’s employment, rather it makes your work easier and reduces the burden on your staff. It is no secret that staff are the most important assets of a practice and their service cannot be negotiated. It is understood that the role or the service of a staff cannot be replaced, and an RCM service provider can never take the place of your staff.

The role of an RCM service provider

The management and other staff members must feel at ease for the smooth running of a practice. The staff are the ones who interact with the patients, collect information from them, and are the ones who make them feel safe and secure. It is the staff that builds the friendly environment in a practice which in turn increases patient visits. Therefore, it becomes important that they are always in a pleasant state of mind, are not overworked, and not overstressed with extreme workload. RCM consists of difficult and complex processes that need to be handled carefully and accurately. Imagine your staff having to deal with all these complex RCM processes along with handling the other important needs such as patient care, treatment, and practice management. It can take a real toll on them. They may feel drained out and stressed with such constant overwork.

In which case, an RCM provider gives you a helping hand as they assist you in navigating through the complex process of RCM without it being a burden to your staff. It takes the weight off the shoulders of your staff and provides them the opportunity to focus their attention on the more important needs of your practice. It gives your staff the time to devote to both new and already existing patients.

Because of the workload and stress, many employees have even quit their jobs at the practices. This could ultimately end up impacting the smooth functioning of the practice. Therefore, partnering with an RCM provider can actually help your practice retain its staff .

Role of staff in RCM

The importance or the role of a staff member in an RCM process is irreplaceable, even with an RCM provider by your side. It is through the staff that the service provider gathers the necessary information related to the patients. Staff act as a mediator between the patients and the RCM service providers. Managing the RCM is nearly impossible without the help of the staff. The staff are the ones who listen to the needs of the patients and address them in a timely manner. They are the ones who help build trust and assurance with the patients. It is through the staff that the patients get to enquire about their worries related to RCM and give their honest feedback. Without the help of the staff, the entire revenue cycle of your practice may get hampered.

Why CareRevenue

We at CareRevenue value the importance of your staff and understand that an RCM provider can never replace your staff. We aim at making work easier and stress-free for your employees. We work hand in hand with your staff to create a peaceful and organized environment at your practice. Constantly keeping track of the revenue cycle prevents your staff from providing the superior care and attention that the patients demand. We help you handle the complex RCM processes so that your staff can direct their focus to other important needs such as patient experience, financial stability, and better alignment of your practice, thereby increasing the workflow of your practice. It becomes advantageous for your practice as you now have two experienced teams concentrated on bettering the revenue and work flow.

Understanding and Interpreting Explanation of Benefits(EOB)

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An EOB (Explanation of Benefits), in the first place, is neither a dental claim nor a bill. It is a document or an electronic statement that is sent out to providers and at times to patients after a claim is processed. The EOB details the dental procedures and/or services that the patients have had and breaks down the costs associated with these services and procedures. It then provides information on what service is covered and to the amount it is covered along with any responsibility that the patient may have. Every EOB is different and reflects a variety of factors that insurers consider for payments to the services rendered and also the deductions from payments. An EOB is usually sent through the mail or can be accessed online. EOBs need to be stored safely and securely in accordance with HIPAA and any state regulations.

Why is an EOB so important?

An EOB is crucial for indicating whether and how a claim was paid as well as any outstanding balance that the patient may be responsible for. An EOB gives patients the chance to confirm that they are being charged for a service or treatment that they have actually received and that the indicated amount is reasonable.

An EOB provides you with crucial information such as the date of service, the procedures conducted, and also the amount processed by the insurance company. It also shows if there are any copays or deductibles for the procedures performed. One section that is important for patients is the amount the patient needs to pay out of pocket, or patient responsibility. This includes deductibles, co-pays, and coinsurance payments. The EOB shows exactly how much of the payment the insurance plan covers and how much the patient is to pay as per the plan benefits. Additional significant data, such as codes for pending status or claim denial, can also be found in the explanation of benefits. Basically, an EOB provides clear information on the limitations of the plan and any balances that are due. 

What gets included in an EOB?

  • Dentist name
  • Claim number
  • Patient identifiable information such as policy number, group number, and date of birth
  • Treatments performed
  • Procedure description
  • The date the procedure was performed
  • Dentist’s fees
  • Amount that was approved and processed by the insurance company
  • Service and coverage information
  • Deductibles
  • Co-pays
  • Coinsurance
  • Coordination of benefits information
  • The portion of the annual maximum that has been used
  • CDT Code (Current Dental Terminology Code)
  • Details on resubmissions needed
  • Codes for pending status or claim denial

Why is it important for patients to read through their EOBs?

With all the codes and numbers, EOBs can appear complex, but it is important for patients to read through the EOB in order to make sure that they have only been charged for services that were received. A claim may occasionally be submitted by the provider which may not contain all the details required by the insurance company to finish processing it. Therefore, understanding and reading through the different sections of an EOB is pivotal in finding and avoiding many billing errors.

Reading through important information like claim codes for pending status, requests for more information, or the denial status which are provided at the bottom of the statement also gives patients the opportunity to follow up with their provider in case any additional information is needed. Patients can be certain that they are paying the correct amount by comparing the patient responsibility amount mentioned on the EOB with the provider’s billed amount. An EOB helps ensure that the insurance benefits are being utilized to their full potential.

Create a Better Dental Huddle Checklist

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Daily huddles have been assimilated into the workings of several industries, including the oral health and dental industry. Practitioners see these huddles as a way to sync up first thing on a working day, organize the day’s tasks and provide an environment to bond. There are, however, several practitioners who find daily huddles unnecessary and ineffective. In several cases, this is, unfortunately, true. When huddles are conducted with no specific format or aim, they do tend to take up a lot of time and provide minimal to no value. The worst part is that most practices, if they fail on their first few tries, completely give up on the idea of a daily huddle. 

When done properly with specific goals in mind, daily huddles can boost productivity and morale. They can serve as an important performance indicator for a practice as they give insightful information about the impact of different strategies on the working and revenue production of the practice. They are meant to be short and succinct. The aim is to have the team/s aligned with the day’s goals and strategize for the day’s undertaking. 

Maintaining a checklist can help set up a huddle system that is pertinent to the practice.

Here are some of the important points that can be added to the daily huddle checklist.

  • A snapshot of the goals that must be reached and the methods for reaching them.
  • Targets that get met and how to improve them.
  • A comparison of the previous day’s actual collection against the projected collection or goal.
  • Updates and follow-ups on schedule modifications from the previous day.
  • Review of winning measures that help staff to attract more potential patients.
  • Discussion of challenges, difficulties, or confusions in the current day’s schedule and plans on how they can be sorted out.
  • Major procedures scheduled for the day.
  • New patients and special-needs patients.
  • Current day’s allotted emergency time. 
  • New and old patient’s details.
  • Necessary assistance with x-rays and other needs.
  • Discussions and confirmations of lab cases.
  • Results from post-op calls.
  • Overdue continuing care.
  • Financial information on the current day’s patients.
  • Patients that need X-rays or photos as per treatment guidelines. 

Daily huddles can benefit practices in a lot of ways. Here are some of the benefits of an effectively conducted daily huddle.

  • Helps in team collaboration and bonding
  • Prepares and inspires the team for the day
  • Can be used as a time-management tool
  • Helps identify any possible hiccups
  • Helps fend off any distractions
  • Can serve as a discussion and team interaction platform
  • Can be a platform to celebrate success

Daily huddles bring with it a variety of benefits. However, they can also become really boring and tiring, especially if there are a lot of topics being covered during one huddle. Each practice needs to prioritize and establish a system that works for them. It may take some time to create the perfect daily huddle system but in the end, it is sure to pay off.

Prioritizing “Days Sales Outstanding” To Get The Best Out Of Your Practice

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Consider a situation where you go through the entire claim cycle only to have it denied or not paid. Consider, also, instances where patient payments are significantly delayed. The time and resources used would seem to have been wasted and it would cause a strain on your practice, wouldn’t it? Now, you would have to contend with delays in receiving payments or worse, unpaid claims. Afterall, isn’t revenue the goal of your practice? Without a healthy revenue cycle, it would be next to impossible to provide the best treatment and care for your patients. How do you circumvent such a situation? We recommend using DSO.

What is DSO or days sales outstanding?

  Days sales outstanding (DSO) is an important metric which measures the average number of days it takes for a practice to collect the complete payment for services provided and is usually calculated on a monthly, yearly, or quarterly basis. The outcome of days sales outstanding is an important performance indicator to how well your practice manages its revenue cycle. Calculating DSO involves dividing the total accounts receivable for a certain period by the net credit sales. This number is then multiplied by the days in that period.

Day Sales Outstanding = (Accounts Receivable/Net Credit Sales) x Number of days

The ideal DSO for a well-managed revenue cycle is less than 45 days. A DSO of more than 90 or 120 days should be avoided as much as possible because it increases the risk of payments not being made. Maintaining a DSO that is neither too high nor too low can seem formidable but doing so can result in better cash flow.

What do the days sales outstanding do for your practice?

  • It shows the performance of your practice’s revenue cycle during a particular period.
  • It shows how quickly patients pay their payments.
  • It helps identify patients or insurance providers who are always late in paying their payments.
  • It helps you understand if you are moving in the right direction with payment collection.
  • It shows if your practice is achieving customer satisfaction.
  • It can act as an early warning sign for the management of your revenue cycle.

How can a standard DSO be maintained?

Have patient payment terms planned well

Make sure that your practice has well-planned payment terms which are neither too tight nor too loose. In general, a practice with more flexible payment terms has a larger DSO than one with extremely strict ones. Although strict payment terms can decrease DSO and increase cash flow, if the payment terms are too tight, chances are high that the customers will leave your practice and find one with loose payment terms. Having well planned patient payment terms helps in ensuring that no patients or insurance providers are at a risk of slow payment or non-payment.

Accurate claims documentation

It is of absolute importance to take the time and have your records accurate before submitting your claims. Practices in a hurry to submit claims are likely to make errors. Even minute mistakes can lead to huge losses for your practice. Any errors in it can cause claim denial or rejection, lengthening the payment process and increasing DSO. Always have accurate patient data and information. Establishing quality-check procedures prior to submitting your claims is a surefire way to reduce these errors. 

Do not overlook receivables

Overlooking receivables is a common mistake that practices tend to make. Just because your practice is making enough revenue doesn’t mean you shouldn’t pay attention to your accounts receivable. You never know how it will impact your practice in the long run. Observe and ensure that your practice gets paid for every service that it provides. Proper management of accounts receivable can help decrease the DSO.

Proper follow-up on claims

Submitting claims is not the last step to the claim cycle. Adequate follow-up is important in making sure that the claims get paid without delays. The longer it takes for the claims to be accepted, the higher the risk of claims going unpaid. In case your claims get rejected, remember to start the resubmission process as soon as possible for a faster payment cycle. A proper follow-up on claims helps your practice reduce its DSO, which makes faster reimbursements inevitable.

Stay focused and determined

Bear in mind that reducing your practice’s DSO doesn’t happen overnight. Making considerable improvements in your DSO and maintaining them overtime requires effort and, at least initially, hard work from your staff. It is, therefore, important to stick to the process and not lose focus. Setting goals and analyzing your previous DSO statistics can help in establishing a robust process, which eventually becomes a frictionless part of it.

On-time claim submission

Late submission of claims is a common reason for denials. Submitting the claims on time should be second nature to your practice, especially if you want to reduce the DSO. It could be your first step in reducing your practice’s days sales outstanding.

Partner with an RCM service vendor

Granted, reducing DSO requires some effort and diligence, which can add to the workload at your practice and for your staff. Your staff would most likely already have a lot on their plate and an increased DSO could prove fatal. This is one of the best reasons for you to partner with an RCM service provider. They provide your practice with skilled professionals who are efficient at clearing unpaid claims, submitting them on a timely basis, and helping you reduce the practice’s days sales outstanding so that your staff are left with sufficient time to focus on the practice.

Client Success Reports: What It Means and Why It Matters

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For a practice, managing the intricacies of the revenue cycle along with other important needs of the practice can be a strenuous and demanding task. This is especially so with limited staff as it puts an extra burden on their shoulders. When a practice partners with an RCM service provider, they are trusting their entire RCM to the provider. It thus becomes the responsibility of the service provider to make sure that the revenue cycle of the practice is handled in a smooth and efficient way without any errors. An RCM provider may be proficient in narrowing down what changes need to be made to have your practice run efficiently. This is how our detailed client success report helps achieve a deeper understanding of the weaknesses in your practice. It can be a guide to the steps you need to take to improve your revenue cycle.

So, What exactly is a “Client Success Report”?

A skilled RCM service provider would compile a detailed analysis of your payment posting, eligibility and benefits verification, and accounts receivable. Partnering with the right RCM service provider gives you access to success metrics and analytics that help your practice grow, in size and scale. Of course, the service provider needs to collect all data regarding the revenue cycle and share it with the practice on time for any improvement to be expedited. A client success report, once prepared, allows you to analyze the patterns in the functioning of your practice. The report then enables you to identify what needs to be done to improve the growth of your practice, most notably its revenue. 

The phases involved in the client success process are:

1. Data Consolidation

Each month, data from the practice’s activities, such as monthly production, payments, adjustments, and accounts receivables, is collected and collated by the RCM service provider.

2. Data Analysis

The data that is consolidated is later thoroughly analyzed. The observations from the analysis highlight opportunities for your practice to improve its work while also increasing its cash flow. 

3. Recommendation

After carefully analyzing the consolidated data, specific challenges in the practice are identified, and a meticulous set of recommendations are created and sent to your practice to increase its cash flow and efficiency. 

Why Does a Client Success Report matter?

  • Provides minute insights into your practice

There are times when providing equal attention to all the aspects of the workings of a practice becomes tedious. This may lead to misses and may hinder the operation of your practice. However, with an RCM service provider giving you on-time client success reports, you get insights into your practice, aiding you in taking steps to prevent errors from occurring or reoccurring. 

  • Identify the source/s of cash leakage

Most practices struggle with revenue leakage and not being able to identify the source of the leakage. Getting an on-time client success report helps your practice identify the source/s of revenue leakage so that you can streamline your entire revenue cycle. This can be an added advantage to scaling your practice higher. 

  • Highlighting Action Items 

Having an on-time client success report also helps you identify the areas in the revenue cycle that need special attention. There may be areas in your revenue cycle that require immediate attention and are critical. A client success report helps you identify just that. As a result, the operational aspects of your practice become effortless. 

  • Strategize RCM improvement

A client success report not only assists your practice in identifying areas of improvement but also provides suggestions or ideas to improve your overall management. Since an RCM service provider is the one handling your RCM, they know exactly how to improve the performance of your practice. Their suggestions or ideas can help you create a strategy for improvement and expansion.

  • Increasing revenue

By helping you identify the areas of improvement and providing you with suggestions to improve your RCM, a client success report specifically helps you multiply the revenue from your practice. 
Being able to provide the best care and treatment to your patients doesn’t always guarantee a successful practice. Success depends on a lot of other aspects, not least of which is your dental revenue cycle management. It’s crucial to comprehend your facts and have a solid action plan. This is where a robust customer success report can play a pivotal role.