Why pre-visit patient interaction is critical financially? How much damage can be done without pre-visit (eligibility, authorization, or referral) test? How frequent are denials due to eligibility, authorization, or referrals for an average practice? What is eligibility test? Who does eligibility test? When to test eligibility? How to manage reminders? How to manage referrals and pre-authorizations?

Why pre-visit patient interaction is critical financially?

The most cost-effective approach to solve claim problems is to prevent them or solve them as early as possible. With time, claim problems grow more expensive and less likely to get paid:

1. The cost of correcting an error doubles at every stage: $2-$5 per correction at the scheduling stage, $5-$10 per correction at validation stage prior to submission of the claim to payer, $10-$20 per correction of a denied or rejected claim.
2. The likelihood of a claim to get paid drops by 1% every day. Therefore, in 100 days, the likelihood of a claim to get paid ever drops below 50%.

How much damage can be done without pre-visit (eligibility, authorization, or referral) test?

1. Denial because of lack of eligibility, authorization, or referral affects entire claim and not just a part of it
2. Some practices experience denials as often as 30% of claims
3. Resolution of denials take 100%-200% longer than non-denied claims
4. Resolution of denials take 30%-40% longer than claims denied for other reasons

How frequent are denials due to eligibility, authorization, or referrals for an average practice?

1. Eligibility: 100%
2. Authorization (preauthorization): 5.5%
3. Referral: 27.5%

(Gavin Hoopes, Practice Management Lab: Making Sense of Previsist, Physicians Practice, March 2006)

What is eligibility test?

1. Payer must identify the patient and display coverage for specific services
2. Payer may also specify deductible amount and copay for specific procedure

Who does eligibility test?

1. Provider
2. Intelligent scheduler

When to test eligibility?

1. Identify two weeks in advance or at the time of scheduling

How to manage reminders?

1. Contact patients 24-48 hours prior to appointment
2. Prioritize reminders by appointment type, medical need, comlpexity, etc.
3. Identify high balance patients upfront and schedule a meeting with financial representative
4. Identify potential no-shows
5. Generate post-visit reminders

How to manage referrals and pre-authorizations?

1. Identify two weeks in advance or at the time of scheduling
2. Prioritize by payer

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