For best results and timely reimbursements, follow-up needs to be rigorous and consistent. RCA has heard from multiple clients that their eligibility vendors failed to stay on top of accounts and the money eventually ran away from them. Noncompliance and difficult patients are pain points that are made easier through constant contact and account monitoring.

From the minute your uninsured patient leaves the hospital, the clock begins ticking and that revenue becomes harder to recover. In many cases, patients are hard to reach by phone, do not respond to mail correspondence and even the most thoroughly trained staff will struggle with gathering the much needed documentation for maximum reimbursement.

We’ve found that weekly communication to the case worker, agencies and the patient is critical to shortening the amount of A/R days to payment. In search of discharged patients, sometimes this consists of measures including home, jail and shelter visits, transportation to and from appointments, translations services and skip traces.

While healthcare providers would prefer that they not be required to obtain retro authorizations, there will inevitably be circumstances that require the dreaded busy work.  However, state Medicaid programs may be slowing down the rate at which services rendered are approved and reimbursed by the program. We have seen an increasing number of retro authorization denials annually across the country, which in many cases result in increased workloads for case management. The work has become so cumbersome that appeal deadlines are often missed, resulting in revenue being left on the table.

In many facilities across the country, case management departments have been charged with ownership of this part of the Medicaid process, which has proven difficult to oversee. An even bigger risk is involved when this work is passed off to the Business Office staff who don’t typically possess the clinical expertise required to be successful in obtaining retro authorizations.

Since RCA provides services as an extension of the hospital’s Patient Financial Services department, we have been asked on several occasions to assist with obtaining retro authorizations after we have successfully secured Medicaid coverage for our patients.  The overall process from facility to vendor doesn’t change and the retro authorization and appeal process fits seamlessly into the daily work queues in which we already oversee.  Immediately following receipt of the retro Medicaid approval, our expert staff begins the authorization process, shaving off precious A/R days by eliminating any unnecessary hand-offs in the process.  In the case of an unfortunate denial, RCA’s clinical staff will make every appeal attempt, and once an authorization number has been approved, it will be submitted to the facility so the account can be billed. Afterwards, RCA will perform routine follow-up to ensure the facility receives payment.

Don’t let retro authorizations and the appeal process put your self-pay reimbursements or A/R days in jeopardy.  This piece of the Medicaid process can be easily handled through your facility’s existing eligibility process.

Bethany Bailey
Vice President of Operations and Eligibility Expert
Resource Corporation of America

Professionals in the Healthcare and Hospital Revenue Cycle industry have seen an increase in denials due to Coordination of Benefits, especially
when it comes to patient coverage (i.e. insurance coverage, federally funded programs and other benefits.) To begin combating the complexity of it all, your facility has probably already tried to implement a process for COB’s. COB is relatively self-explanatory in its definition; however, effectively performing the function has proven to be quite a bit more involved when the patient doesn’t comply with what is needed from them.

When payment is denied by the payor, because there is belief of existing or additional coverage, that account can quickly become a self-pay account if the appropriate forms are not successfully completed. As a self-pay eligibility vendor, RCA has a vested interest in helping our clients recover those dollars. RCA already performs rigorous account follow-up and has existing resources that are complimentary to an effective COB solution.

Worked much like a self-pay referral, the COB account will require completion of a necessary form (which can be found online), additional information to process the claim
and then actively pursued until resolution. COB services include identifying an accurate payer, initiating billing and securing payment. Additionally, our representatives will coordinate phone calls between the patient and insurance company and will conduct home visits to ensure that the information that is needed to pay the claim is collected and sent to the insurance company. After the information has been submitted, we continue follow up with the insurance company until payment, to ensure that the insurance company does not need any additional information from the patient.

Coordination of Benefits has become increasingly popular with insurance and software companies and their methods are only moderately effective; however, if an account is non-compliant for more than 30 days, you may want to consider “Coordinating another COB Vendor”, who will be more rigorous in the account followup.

Bethany Bailey
Vice President and Eligibility Expert

Qualifying self-pay patients before they become self-pay patients 

When RCA rolled out our Pre-admit screening services (years ago) we knew we were headed in a direction that no other third-party eligibility vendor had gone before.  Our clients were very excited about this new service and the overall response from the industry was positive.  Pre-admit screenings helped drive insured patients to the hospital who would have otherwise been self-pay.  Surprisingly, this service is still just as cutting edge as it was 10 years ago and we often find ourselves introducing the service during meetings with hospital management.

The process is simple and easily integrated into existing or new eligibility operations.  Our representatives receive referrals from clinics, hospital staff, financial counselors and other community sources prior to a patient’s scheduled service/appointment at the hospital.  RCA then conducts the eligibility screening, gathers the necessary documents and assists with the application process to help enroll the patient with Medicaid.  Procedures that are related to surgery, pregnancy, cancer or any other condition that would eventually lead them to your facility can be leveraged to begin qualifying the patient for financial assistance before it impacts hospital resources and A/R.

If you find yourself like many other facilities, and are seeing an increase in self pay volumes, it may help to consider the lasting benefits the Pre-Admit service can offer the hospital, the physicians and the patients. A successful Pre-admit program will result in quicker certifications & reimbursements, more billable visits and increased coverage on previous medical bills. Feedback from doctors and patients have been favorable toward the pre-admit screening, praising the improved communications and helping to build relationships and loyalty to the hospital.

HOUSTON, Jan. 31, 2017 /PRNewswire/ — Third Party Medicaid Eligibility company, Resource Corporation of America (RCA), hosted a Ribbon Cutting Ceremony on Friday to celebrate the grand opening of its new support center and regional office expansion.  One of several regional offices in the country, the RCA Houston office is the largest and is located just minutes from the Texas Medical center, the largest medical complex in the world.

The expansion project began less than a year ago, after the company experienced significant growth from new contracts.  In 2016, RCA hired over 120 employees and the Houston regional office more than quadrupled in size.  Additionally, RCA was recognized and listed on the Houston Chronicle’s Top Workplaces survey.

After 23 years of being an industry leader, the privately owned company decided to skip the “growing pains” and made the decision to build out their office knowing it would benefit all parties.  “The need to expand our office was an easy decision and the project began without hesitation,” said Frank Dominguez, Chief Operating Officer for RCA, “RCA’s hospital partners rely on us to provide a high quality service and to be a resource for their facility and their patients.  The additional highly trained staff and larger departments ensure our hospital clients receive the maximum amount of reimbursements.”

The ceremony was attended by employees and partners from both ends of the country and was followed by an open house for clients to tour the building and meet key department managers.

One aspect of third-party eligibility that is likely not getting enough attention from your vendor or in-house team is SSI/SSDI reimbursements. This is where we see significantly more at-risk dollars and, when followed through properly, makes up the bulk of conversions recovered for our hospital clients. Based on data we collected firsthand, while SSI/SSDI makes up only about 20-40% of self-pay inventory it averages a whopping 60%-80% of pending dollars, on average. Note that while Medicaid accounts are expected to decrease in expansion states, SSI/SSDI is still an important piece of the overall puzzle, no matter expansion or non expansion. We use those averages as a starting point when we are asked to conduct eligibility performance evaluations.

Our S.O.A.R. (SSI/SSDI Outreach and Recovery) certified experts have over 22 years of experience handling SSI/SSDI claims. Through consulting and providing services to hundreds of providers in those two decades, we have seen that the following errors occur within the SSI process:

Not knowing where the patient is in the process – This seems silly, but it’s true. A lot of eligibility teams do not continue regular follow-up on SSI accounts. In some states, the SSI/SSDI process can take upwards of 2 years and this causes a misconception that accounts won’t progress for months at a time. However, there are many stages to the timely process and weekly or even biweekly follow-up can help hospitals know where the patient is in the process and also increase the approval odds by ensuring the Social Security Administration receives everything they have requested in a timely manner.

Returning referrals to the hospital due to outside representation – When a patient utilizes an attorney or other outside representation for help with their disability claim, it is often incorrectly assumed by the vendor that communication has been compromised and that they will not get the information they need to continue working the account. Returning those accounts negatively affects your bottom line because there are ways to help the representation and the Social Security office without compromising the patient’s relationship with their representative. Therefore our eligibility best practice rule #1 is to follow-up through reimbursement to the hospital.

Informational Claims (Dummy bills) aren’t being filed in time – Do you know your state’s Medicaid filing deadline? Some states have become savvy and will not pay SSI/SSDI cases if they never receive the bill or an application to protect the dates of service. Your team should be submitting timely claims in order to protect all dates of service for the patient and then rigorously following the account so the hospital can collect in the instance a patient is approved for Medicaid during the SSI/SSDI process. Accounts not filed in time or only sent through a batch filing software could be easily lost forever.

Stopping at mediocre – Often times our SSI/SSDI cases need a little extra attention. This means immediately filing appeals, providing patient transportation to doctors’ visits, regular physician follow-up and obtaining medical records. These value-added services reap big rewards when it comes to shortening A/R days.

Bethany Bailey
Vice President and Eligibility Expert