RCM tip of the day: Renew focus on patient eligibility verification to reduce claim denials


Healthcare organizations should focus on multiple aspects of the revenue cycle to reduce claim denials, particularly patient eligibility verification, according to Dustin Hamilton, director of product at Louisville, Ky.-based ZirMed.

Mr. Hamilton shared the following tip with Becker's Hospital Review.

"In healthcare today, one in five claims is denied or delayed and a startling 90 percent of those denials are preventable. Yet, most healthcare organizations still focus on appealing denials rather than addressing the root cause of the issues so they can avoid them.

"To implement a denial prevention strategy, health systems must take a multipronged approach. One key piece of that strategy is a renewed focus on verifying patient eligibility. The vast majority of denials — as much as 75 percent — are the result of problems with patients either being ruled ineligible or not covered for certain services. It only takes a small error, or one missing piece of information, to turn a legitimate claim into a denial. Manual approaches to verify eligibility and coverage of services during scheduling and registration processes are time-consuming and laborious, often requiring multiple phone calls or logging in to a payer's website. Even if all the information is obtained, if it is entered incorrectly into the system it can still result in a denial. Eligibility verification technology can solve these issues, ensuring a patient is eligible for all the intended services before they are provided — right up to the time of check-in. Automating the information-gathering process ensures that the patient and service data is entered accurately, without the risk of introducing human error. By sending quality information to the back-office staff, the organization can ensure claims are as clean as possible, reducing denials and the administrative burden of attempting to fight them later."

Read more about how hospitals can improve RCM performance here.

If you would like to share your RCM best practices, please email Kelly Gooch at kgooch@beckershealthcare.com to be featured in the "RCM tip of the day" series.


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