Practice Management Alert

Expert: There’s no single explanation for why the payer deems a patient ineligible.

Patients who are ineligible for benefits that you thought they had are a potential headache for every medical practice. In fact, some experts say it’s the most common billing mistake that medical practices make that is causing them denials or recouped payments.

“Eligibility denials are by far the most common denial,” says Leah Paraschiv, CMPE, of MSOC Health in Chapel Hill, NC.

Check out Paraschiv’s top tips on reducing eligibility denials:

1. Get rid of simple mistakes on the front end. “Typos in the patient’s demographic information, incorrect choice of claims address or electronic payer ID number, etc. - can cause major headaches on the back end,” Paraschiv explains.

Due to the exponentially larger volume of health plans on the market since the ACA, growing popularity of TPAs, and the trend in carrier mergers or consolidations resulting in changes in electronic and/or paper claim submission addresses, it is more difficult than ever for reception staff to determine the right place to file a claim for a given patient.

2. Go past insurance cards to verify patient info. “Insurance cards don’t always tell the whole story,” says Paraschiv. “It is vital that practices verify eligibility on every patient, preferably at every visit or at least once every 30 days or every calendar month.”

You can verify a patient’s eligibility electronically for most payers, “provided that the practice takes the time to set up their practice management system properly,” explains Paraschiv.