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Why Struggling Hospitals Need Insurance Discovery for Financial Stability

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How revenue cycle managers can overcome the challenges of changing eligibility and capture every billing opportunity possible. 

July 2, 2020 

When managing a revenue cycle, there are several challenges when it comes to identifying undisclosed eligibility. Patients go in and out of coverage, don’t always know they have Medicaid coverage or become eligible for retroactive coverage long after receiving care. It is not easy to successfully run eligibility checks on every patient walking through the door, let alone continuously monitor for retroactive coverage. Missing eligibility and retroactive coverage hinders hospitals from recovering entitled revenue.

Don’t leave money on the table

Numerous changes to health insurance plans make it nearly impossible for revenue cycle teams to track. Current COVID-related spikes in unemployment is also amplifying the changing patient eligibility challenges. These challenging scenarios include:

1.      Loss of many company-sponsored plans.

2.      New policies obtained through the Marketplace.

3.      Increased Medicaid eligibility.

4.      Returned to work with company-sponsored plans reactivated.

Numerous changes to health insurance plans at a frequent rate make it nearly impossible for revenue cycle teams to track.

When you’re not aware of changes to someone’s insurance or eligibility status, money is left on the table by not billing the appropriate payer. The issue is compounded as people become eligible for retroactive coverage through Medicaid. It’s hard to keep track of uninsured patients that transitioned to Medicaid after you treated them, and each occurrence leaves hundreds, if not thousands, of dollars on the table.

Missing out on revenue means a longer road to normal

The COVID-19 pandemic altered everyone’s reality. Healthcare organizations (HCOs) doing well before the outbreak are now seeing cash-flow shortages. HCOs struggling before the epidemic are wondering if they will even keep the doors open.

The road to recovery gets much longer by not knowing someone’s current insurance status and the details to bill the payer. However, if you can address those missed billing opportunities, you can survive the day and flourish tomorrow.

Leveraging technology

If you’re looking for easy, low-risk ways to super-charge revenue, technology can help. Insured patients are commonly misclassified as self-pay for a variety of reasons. About 5% of the patients classified as self-pay have coverage that had been missed. Even more patients will have changed payers without informing you.

With the right technology, you can effectively search for missed coverage with Medicaid and other major payers, monitor Medicaid for occurrences of retroactive coverage, grow revenue by potentially millions a year, and do it all without relying on staff to do random, manual eligibility checks. If you find the right vendor, getting started is simple and you aren’t required to pay anything until you have seen payments yourself.

Databound has helped many HCOs bring more money in to their organization. For example, Norton Sound Healthcare, an 18-bed critical access hospital, recognizes about $2,500,000 each year by using technology to identify missed billing opportunities.

Creative solutions to complex problems

COVID-19 aside, it is critical that HCOs, especially those caring for under-served populations like FQHCs, Rural Hospitals, and Safety Nets take advantage of every opportunity to bill commercial and government payers.

The reimbursements are higher, faster, and the cost-to-collect is a fraction of what it costs to collect self-pay dollars.

Insurance discovery is a critical component in maximizing your reimbursements so you can deliver quality care to the communities you serve.


Learn more

Ready to infuse your organization with revenue and make sure you aren’t missing any billing opportunities? Check out our new risk-free tool − BOOST: Backlog Search™ − giving you and your staff a chance to prevent missed billing opportunities.


Written by Mike Burhans, MBA, CRCR - Relationship Manager

Mike Burhans, MBA, CRCR - Relationship Manager

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