‍Patient financial clearance systems in the US are antiquated and inefficient. The time has come to understand these systems better and modernize them from the ground level up.

The business of running a profitable healthcare practice has seen seismic shifts in the last few decades. Traditional patient eligibility and benefits verification systems used at modern healthcare practices are quickly becoming inefficient and inadequate. These systems were originally designed to simply confirm that a patient is eligible for insurance. However, current verification staff fights with complex information exchanges and ever-changing requirements from the payers.

As demand for specialization-specific healthcare services soars amongst patients, outdated insurance verification processes continue to pose operational challenges for practices that require more advanced systems to provide accurate and efficient care.

On an average healthcare practice deals with about 20 different insurance companies in a day, notes AASM. The process of logging into individual online insurance portals for each patient, interpreting coverage information, and in some cases, being on the phone with insurance companies for hours can be tedious and frustrating for both the patient and the sleep center staff -- especially when patients are anxious about their upcoming appointment. Long wait times, complex paperwork, and denied claims can all contribute to delays in care and financial losses.

When EHRs aren’t enough

You know the feeling of being trapped in insurance purgatory. You've spent hours on hold, only to be disconnected or transferred to someone who can't help you. Your staff is feeling the same way, and your patients are starting to get frustrated.  When you think of patient financial clearance, it isn't just another RCM checkbox; it's the foundation on which the entire revenue cycle stands. Patient financial clearance acts as a proactive gatekeeper, ensuring financial clarity before services are rendered, whereas revenue cycle management (RCM) is a broad set of activities like claim coding, submission, payment processing, and A/R follow-ups that drive revenue collection after services are provided. [Read more on this here].

Here are a few factors that could be further contributing to operational issues:

1. Incomplete Eligibility Information: Many practices rely on Electronic Health Records (EHR) for insurance verification, which often provides only basic information about a patient's insurance status. It checks if the insurance is active or not but doesn't provide detailed benefit coverage information. Third-party billing vendors also struggle with manual tasks and are forced to work with multiple portals, which can lead to delays and errors.
2. Lack of Service-Level Benefits: To efficiently plan and provide services, practices need access to service-level insurance benefits information. Generic insurance verification software may not offer this granularity, leaving staff to interpret vague benefit summaries -- and often wasting time to confirm the benefits again with insurance companies over the phone.
3. Specialized Services: Practices often offer specialized services like diagnostic tests or other treatments, which may not have clearly defined coverage and benefit information from insurance providers.
4. Manual Data Summarization: Even if staff can access benefit information online, they often spend significant time manually summarizing and recording this information for each patient, leading to inefficiencies.‍
5. Patient Estimates: To communicate patient financial responsibility accurately, the benefits information must be summarized clearly. Practices often lack the best practices in how to communicate the patient's financial responsibility, resulting in confusion and poor collection from the patients.
   ‍
   ‍

The pitfalls of inaccurate or missing patient's information

Inaccurate or missing insurance information can have profound consequences for practices. Patients who are uncertain about their out-of-pocket expenses may cancel appointments or not show up, impacting revenue and patient care.

• Claim Denials: An alarming percentage of claim denials are attributed to errors in obtaining accurate insurance verification information. These denials translate into revenue losses and administrative headaches.
• Patient Dropouts: A significant portion of patient dropouts can be attributed to concerns about out-of-pocket financial responsibility or delays in obtaining appointments due to insurance verification issues.
• Staff Productivity: On average, healthcare staff spend 20-30 minutes per patient to secure financial clearance.  This is a significant amount of time that could be used for other tasks. This manual process not only hampers productivity but also contributes to staff turnover.
• Appointment Delays: The average number of days of delay in setting up a patient appointment due to lack of insurance coverage clarity is a key metric. Delays can lead to frustrated patients and missed revenue opportunities.

The good news is that there are things you can do to improve the efficiency of your insurance verification process. Modernizing the insurance eligibility and benefits verification process with intelligent workflow automation is one way to address the problem at hand. Thus, eliminating the necessity of navigating various record systems to initiate timely care and ensure accurate reimbursements.

‍

Price Transparency with Clear Patient Financial Responsibility Sheets

Patient financial responsibility sheets are detailed breakdowns of potential costs, provided before procedures. These include the cost of the treatment, potential insurance coverage, patient's out-of-pocket estimate and available payment options. This transparency lets the patient understand their financial responsibility, choose preferred payment installments, and avoid surprise bills later. It reduces friction and fosters trust, making upfront payments less daunting and leading to smoother experiences for both the patient and the practice.

For healthcare providers, the benefits are equally tangible. Clear communication translates to reduced bad debt and a more predictable cash flow. This financial stability allows practices to reinvest in patient care, from improving technology to expanding service offerings. Ultimately, the patient payment estimate sheet becomes a bridge of understanding, ensuring both parties are on the same page financially. This mutual trust creates an environment where healthcare can focus on its true purpose – transparency-- providing patients with the highest quality care, unburdened by financial uncertainties. Experts recommend making yourself familiar with the best practices for upfront collections- which include implementing transparent pricing models, investing in price estimation tools and more which you can find in our previous article here.

‍

What is Intelligent Workflow Automation for Healthcare Practices?

A modern system such as Aarogram's SmartVerify Insurance Engine can pull patient's eligibility and verification data from various insurance companies and other sources using API or bots, parse the data for an accurate service level info and summarize in a simple sheet for consumption of the staff or the patient alike. This can conserve tens of hours' worth of time each week and free up staff members to focus on more complex tasks. Intelligent workflow automation can allow staff members to focus on more complex tasks, such as providing personalized care to patients, managing complex submissions, and improving the patient experience.

The future of benefits verification at healthcare lies in intelligent, connected systems that streamline the process from start to finish. By adopting advanced platforms like Aarogram's SmartVerify, practice managers and owners can optimize operations, enhance patient care, and boost their bottom line. Achieving a frictionless insurance verification experience requires not just accurate coverage data but also efficient data management and communication.

A solution like Aarogram's platform automates the entire process in real-time, empowering staff to make informed decisions and provide financial clearance to patients promptly. Aarogram's SmartVerify system is an intelligent workflow automation solution that integrates easily with existing systems including EHRs at practices and other types of practices. It automates workflows related to eligibility and benefits verification, prior authorization, and payment summaries, which can help practices reduce administrative costs, improve efficiency, reduce the risk of errors, and provide better patient care.

To learn more about how Aarogram's SmartVerify system can help your practice automate payer requirements, improve patient experience and bring cost efficiency, feel free to contact us.

Note: A version of this post was published earlier specifically for sleep centers, which you can read here.