Most claim denials are due to the lack of verifying benefit information prior to services being provided. Insurance verification process is crucial for all hospital encounters, whether inpatient, outpatient or ambulatory care. It will ensure that the hospital or physician receives payment for services rendered and will help determine the patient’s share of the charges referred to as the patient’s responsibility.
The overall theme of this year’s HFMA Annual Conference is “Transforming the Business of Healthcare,” and it is right on target. No other industry is experiencing more evolution and transformational change than healthcare. It seems that the only thing we can count on is change — this is even more true for the business side of healthcare delivery.
In medical billing terminology, eligibility verification, pre-authorization, prior authorization and pre-certification are terms that may be used interchangeably to mean that for certain situations and procedures, providers have to contact insurers in advance and obtain a certification number in order to be reimbursed properly (or at all) for services. Insurance verification and insurance authorization services play a vital role in revenue cycle management. In fact, most claim denials happen when a patient is ineligible for services billed by the provider.
The RevCycle Intelligence e-newsletter reported recently that 80 percent of hospitals are vetting full revenue cycle management (RCM) outsourcing. The demand to outsource full RCM is up 86 percent from 2015 among hospitals and inpatient organizations. Approximately 80 percent of hospital leaders in a new Black Book survey of 709 C-suite executives, board members, and senior managers at hospitals and other inpatient organizations said they were vetting or considering outsourcing full RCM by 2019.
Many healthcare providers are under the impression they can assess their financial health by evaluating cash flow only. However, cash flow is just one factor in revenue cycle management (RCM). To maintain a healthy revenue stream, healthcare providers need to understand the other important metrics that should be calculated and reviewed when evaluating their revenue cycle.
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