'Preventive care' in billing decreases denials and increases satisfaction

Faced with low reimbursement rates and picky payer specifications, it's critical that you get paid every penny you're due for treating patients. You know how to properly take a claim from patient encounter to submission, but how much preventive care are you taking with your claims before patients reach your office?

Incorporating pre-emptive processes into your operations can prevent denials, increase efficiency and keep your patients happy. Take these preventive measures to keep payments - and patients - moving smoothly through your office.

Step 1: Pre-visit data reviews and updates

Typically patients update their personal and insurance information after signing in at your office, right? For several reasons, that should change.

Your front desk staff, busy as they are managing incoming and outgoing visitors, may forget to ask the patient for her latest insurance card or updated address.

Or even if they do remember, when the patient hands back a demographics sheet, your staff could fail to input the new data right away, overlook a change to the info (like a corrected street name) or mis-key the data into your system.

Mistakes in demographic info are a common reason for claim denials. Having existing data updated prior to a visit decreases your likelihood of incurring denials, while also lessening paperwork and making check-in quicker and more efficient.

When a patient calls to schedule, have the answering staffer first book the visit, then read the existing info in your system to the patient and ask her to confirm or update it. Name, DOB, phone, address and SSN (if necessary) should all be verified.

Then have the patient dictate her insurance information in its entirety, including carrier, member number and group ID. If the insurance has changed since the patent’s last visit, your staff can make the necessary updates. If it hasn’t, this is their chance to authenticate existing info.

And if you know there’s paperwork the patient must complete – HIPAA acknowledgments or consent forms, for example – now’s the time to send them to the patient (via email, if possible) to have them brought in on the appointment date, which saves you the back-and-forth before the encounter.

Step 2: Check for eligibility and authorization

Another item to ask for during that initial scheduling call is the phone number on the back of the insurance card. It may come in handy for your staff while verifying the details of the patient’s coverage from her insurer, which should be done at least one day prior to the appointment.

Someone on your billing staff should be tasked with doing whatever’s necessary to execute eligibility checks. Some insurers make this easy through tools available online, while other payer companies may require that you call to verify specifics. If you’re lucky, your practice management software will automatically check eligibility for you, as some current systems now do.

Regardless of whether a human or electronic entity executes the checking for you, eligibility is successfully verified when your practice can answer the following questions:

  1. Will the patient’s insurance (and coinsurance, if applicable) be in effect at the time of visit?

  2. Is your practice in-network for the patient or not?

  3. Will the patient be expected to surrender a co-pay or other payment for this visit? If so, how much and why?


This step is also the point when your staff should review the patient’s outstanding balances, check whether any referrals or pre-authorizations are required for procedures being rendered at the appointment, and track down all necessary documentation.

Step 3: Communicate and resolve

If you discover problems during steps 1 or 2, don’t just sit on the information and go about the visit and claim-filing process as usual – tell the patient what snags you’ve encountered.

Patients often have little understanding of what the process of billing their health insurance entails; small issues can escalate into frustration when they’re left in the dark. Lift the veil on the situation by sharing any troubling findings with them as soon as possible.

Did you discover that a change to your patient’s health plan makes your practice out-of-network? Tell the patient and explain how that changes her financial responsibility. Same goes for an authorization problem or existing balance you expect her to pay in full before the encounter.

Consider tasking a dedicated employee – a patient billing rep or “financial advocate” – as the designated informant on such matters. Patients appreciate having someone on their side and knowing ahead of time what they’ll be in for at check-in and check-out.

Staying ahead of the game has other advantages, too, like giving you opportunity to fix an issue before it holds up payment. If you never received the referral documentation, you have time to ask the patient’s primary care provider to fax it over. If the authorization timed out, you can re-obtain it and reschedule the appointment if necessary.

Using “preventive care” and effective communication may take extra foresight and preparation, but they’re changes that will reap improvements quickly. As you lessen the amount of denials you receive, increase the efficiency of your workflow and improve patient satisfaction levels, you’ll appreciate how thinking ahead pays off.

What steps to you take before a visit to ensure effective billing?

Madelyn Young is a content writer for CareCloud who specializes in covering practice management, medical billing, HIPAA 5010, ICD-10 and revenue cycle management. You can read her work on Power Your Practice and the CareCloud Blog.