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Overhauling the eligibility process

The eligibility process is a complicated thing, but now might be the time to examine its functionality

With implementation of the Affordable Care Act fast approaching, the eligibility process could be queuing up for an overhaul.

As potentially millions more patients lining up for care, there will likely be an increased need for providers to verify eligibility and patient financial responsibility before procedures or examinations are performed.

Unfortunately, overhauling the eligibility process won’t be a simple thing, say experts. The current process is often complicated, and requires millions of dollars and countless hours spent calling insurance providers.

[See also: Eligibility screening: Is your organization ready for a fresh approach?]

“For one eligibility transaction, you have four layers of entrenchment,” said Katelyn Gleason, CEO of Eligible, an online insurance verification provider. “You have the health plan, a clearinghouse, the provider’s system – whoever builds that system – and then the provider.”

With the implementation of the ACA, clinics and ERs are predicting a surge in patients coming to their facilities with questions on how to enroll, said Ankeny Minoux, COO of Pointcare, a software company, making the eligibility process all the more bogged down as healthcare workers try to handle the extra load.

“That’s why some forward-thinking clinics are looking for ways to screen and enroll people now – so there will be less of a rush in October and on into January when the ACA formally kicks in,“ said Minoux.

Further complicating the eligibility process is increasing consumer demand to know the cost before saying yes to procedures, said Adam Powell, PhD, president of consulting firm Payer+Provider Syndicate.

“As patients are increasingly paying a greater portion of the cost of their care, they are demanding actionable information on the price of care at specific sites of service,” Powell said.

In order to balance patient demand for cost transparency, the added number of confused patients and the regular eligibility process while building patient volume, Powell suggests providers should build their capabilities.

“Investments in the infrastructure necessary to estimate patient financial responsibility can enable practices to grow their revenue with more consumer-centric plans,” said Powell.

 

 

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