The Importance of Insurance

Verification, Fee Transparency and

Bundling

Helen Lowenwirth, MBA, CASC

Administrator
East Side Endoscopy, LLC
 East Side Endoscopy, LLC

New York State Certified Ambulatory Surgery Center / AAAHC accredited

Single Specialty Endoscopy (soon to be Dual)
Affiliated with Mount Sinai Beth Israel
Performed its first procedure in January 2010
10,000 Procedures Annually
23 owner physicians with independent practices serving the community
31 credentialed physicians performing procedures
Medical Director is Dr. Brett Bernstein
We have a very successful Charity Program and have performed over 600
free screening colonoscopies as part of the NYC Department of Health-
Community Cares Project

2
 The objectives of this presentation

To explore what insurance verification really means and why it is so

important.

How it can impact your operation, profitability and improve overall

operations.

Recognize the increasing importance of fee transparency to patients.

Talk a little about “bundling”.

3
 Verification Defined

The process of establishing truth, accuracy or the validity

Insurance Verification - Is the process of checking patient’s

insurance coverage and benefits prior to date of service to insure
payment for services

4
 The Importance of Verification

Why is verification so important ?

It is a critical component of revenue cycle management

Claims will be paid if conditions for coverage are met…

Insurance is inforce

Premiums are paid

The service is covered

Deductibles have been met

If it is medically necessary

5
 The Importance of Verification

• When should insurance be verified ?

Every time the patient makes an appointment

And Again on the Date of Service

And Again for a follow up

6
 Gatekeepers

Who Verifies ? The front office is your gatekeeper!

Verification is the responsibility of the front office..

Should be done at the time of scheduling

Most verification is done on-line

By the time your billing staff gets it ..it is too late

Verification should be done AGAIN at the date of DOS

Copy of card
Address
Other ID

7
 “ But I have insurance !” ….

What do we Verify?

Eligibility

Coverage/Benefits

Policy Limitations

Financial Responsibility

8
 “ have you met your deductible” ….

What do we verify?

Eligibility:
If the coverage is in force (effective date)
Premiums are paid

Coverage:
Is it a covered service (i.e. well exams, sick visits, maternity, etc. )
Who is the Subscriber (Patient, Spouse)
Primary vs. Secondary
In Network vs Out of Network

9
 … they paid the last time I was here” ..

What do we learn when we Verify?

Policy Limitations:
Preventative services
Contracted services
Are pre-authorizations or pre-certifications required
Pre-existing

Patient’s Financial Responsibility:

Co payments
Co insurance
Deductible

10
 Why are claims Denied

Demographic Data Medical Necessary

DOB doesn’t match Reasonable, necessary for the
Subscriber # missing /invalid diagnosis, injury or disease
Group # missing or invalid (do you have the documentation)

Coverage terminated Coordination of Benefits

Eligibility Primary vs Secondary
Not eligible at DOS
Liability Carrier
Pre-Authorization/ Precertification is Worker comp/No fault
(was) required
Missing or Invalid Codes
Authorization timed out
Timely Filing
Non- Covered Services
(some carriers require waivers for No Referral on file (from PCP)
these so you can bill patient)

11
 Life Cycle of an Endoscopy Procedure

1. Patient makes 7. Appointment

6. Pre-call
appointment Confirmation

Verify eligibility and

benefits at physician 5. Insurance cycle 8. DOS
office

4. Procedure
3. Physician
is 9. Post- call /follow
recommends
scheduled/Instructions up
procedure

12
Billing Process

Make an Pre-certification
Verify Pre-
certification
appointment

Review with
patient /Discuss
Eligibility Coverage financial
responsibility

Pre-registration Verification
DOS
Rerun!
 Verification Process

Call patient to
1. Patient makes Verify
review financial
appointment authorization
responsibility

Verify eligibility
and 5. Obtain DOS
authorization Collect co-pay
Benefits

call patient
3. Needs referral
/referring 9. Submit Claim
/pre-certification
physicians

14
 Fee Transparency

Providers are collecting a increasingly higher share of fees from

patients.

Driving more of a consumer oriented approach to obtaining services

Patients are asking “how much is this going to cost ME”

High deductible Plans

Co-pays/co-insurance

Ancillary services (anesthesia, pathology, labs, imaging, etc.)

 Determining Patient Responsibility

Discussing money is never easy, especially in healthcare situations

Patients do not (even try to) understand their insurance coverages

We must educate our patients about their policies and coverages

Staff must be trained to answer patient questions

Access to fee schedules to calculate co-insurances

Make the calls to determine remaining deductibles

Call in advance to advise patients of their responsibility

 Determining Patient Responsibility

The consequences are real

For Providers

People postpone treatment

Don’t take medication

For Patients

Increasing bad debt for providers

Increasing patient (consumer debt)

20% of adults struggle to pay medical bills
3 out every 5 bankruptcies due to medical bills; one study 62% with 78% having
insurance
Leading cause of bankruptcy; more than job loss, overuse of credit and divorce. or
 Data Elements in a chart

Demographic
• Name, Address, Telephone, e-mail, SS#, DOB, DOS, Emergency Contact, Employer

Insurance
• Policy #, Group #, Subscriber #, PCP, Referral, Pre-authorization – aka- pre-cert, Verification,
Eligibility, Benefits, Primary, Secondary, Active Coverage, Benefits, Deductible, Co-pay, Co-
insurance, Out of Pocket, Stop Loss, Insured, Relationship to Insured, Guarantor, Claim, CPT,
ICD-9 (now ICD-10) Bills, Statement, EOB, Collection.

Clinical

• Symptoms, consult notes, H&P, Indications, NPO, BMI, Medications, Allergies, Advance
Directive, Glucose, BP, prior surgeries, do you smoke ?, do you drink ? Implants ? Dentures,
 The anatomy of a visit

• Family members • Consultation

• Preparation instruction
• Insurance
•H&P
• Work /School • Diagnosis
• Transportation • Treatment Plans
• Escorts • Risks & Benefits
• Advance Directives

Social Physician

RNs/ NPs/
Insurance
PAs/Techs
• Pre- assessment •A
• Consenting • Insurance Eligibility and
• Pre-Op Care Verification of benefits
• Post- Op Care • Advising patient of financial
• Discharge responsibility,
• Follow up call
• Collecting $$$$$

19
 Bundling

Cost Quality Transparency

control Improve
ment
Links payment for Accountable
multiple for outcomes One Fee
services/providers Assuming risk Inclusive of all
Seek out more on following ancillary
efficient facilities and ancillary service
(ASC vs services “no surprise
hospital/OBS) Reinforces bills/
Compliance

20
 Bundling

More conducive to some procedures where an “episode of care” can be clearly defined
from beginning to end.

Colonoscopy
Joint Replacements
Cardiovascular
OBG

Key Factors
Must know your cost
Assume Risk
Shared Savings
Relationship of Multiple parties
 Conclusions

Insurance Verification is a critical component of revenue cycle management

The current environment is very complex with many factors working against
healthcare providers to collect payments

Being proactive and transparent helps manage patient expectations and

compliance with financial responsibility

We have to start looking at services that are conducive to fee bundling.

Proactively discuss with payers to promote cost control and efficiency and
quality of care.
 Thank you !

Helen Lowenwirth, MBA, CASC

Administrator
East Side Endoscopy, LLC
www.esecgi.com
hlowenwirth@esecgi.com