How Automating Patient Insurance Verification Reduced Denials

Eliminating the manual backend task of checking patients' insurance eligibility reduced denials and AR days at an orthopedic surgery practice while also getting more staff face-to-face time with patients.

When it comes to healthcare, Kim Wishon has a major pet peeve. "My biggest problem that I have is the administrative burden of healthcare," says Wishon, CEO of Watauga Orthopaedics, a private orthopedic surgery practice based in Tennessee.

Evidence of this "broken" health system, she says, are the number of people who work "behind the scenes" to deal with the ever-changing minutia of insurance coverage, coding, billing, and more. 

"None of these people actually ever speak to a patient," she says. "They're doing so much busy work, but that doesn't increase the quality of patient care."

That's why when Watauga Orthopaedics decided to switch its EMR system, it chose one that would remove some of that administrative burden by automating tasks that were previously very labor-intensive.

In fact, one of the system's tools—automated insurance eligibility checking—allowed Watauga to reduce its denial rate, significantly cut down accounts receivable days, and eliminate an entire backend department altogether, allowing those employees to be relocated to more patient-centric positions.

Watauga Orthopaedics is far from alone in its administrative burdens. In fact, a JAMA study from last year showed that in the United States, the administrative costs of care accounted for 8% of healthcare spending, versus 1% to 3% in the other countries.

Buried Under Busywork
 

Before using automated insurance eligibility checks, Wishon says Watauga Orthopaedics was reliant on a "person-centric model." There were a lot of tasks that needed to be accomplished in order to get paid and the private practice needed a person to do them—three people, in fact: Watauga's eligibility department was made up of three full-time employees.

"All they did, all day long, was either call insurance companies or scour websites—if that information is available—and make sure the [patient] had the coverage and what kind," Wishon says. All the work was done manually.

"That was a very broken and labor-intensive process," she says.

Doing manual eligibility checks for scheduled patients was laborious in itself but doing manual checks for walk-in patients added an additional layer of burden to an already burdensome process.

Between Watauga Orthopaedics' two locations, Wishon estimates that they see between 100–150 walk-in patients per day, and about 2,040 total patient visits per week. Walk-in patients would have to sit and wait while their insurance was checked before they could see a provider.

Implementing Automation
 

All that has now changed. Using the tool athenaOne, from athenahealth, Watauga Orthopaedics can automatically verify insurance eligibility within seconds.

The automated system has made a difference in four main ways:

1. Reduced denials: Watauga Orthopaedics' denial rate has decreased from 11% to 4% from when it first implemented the system several years ago until now.

Automation not only means that insurance checks happen immediately, but they also help to identify human errors and insurance changes before the practice bills the insurance, ensuring clean claims.

For instance, if the system says a patient isn't eligible, the team can quickly pinpoint whether they've made a mistake in entering the information, such as transposing a number or putting in the wrong birthday, or if it really is an issue with insurance coverage.

For scheduled patients, the system actually performs the insurance eligibility check twice: Once when they're first scheduled and again two days before their appointment.

Patients who have long waits between making their appointment and seeing a provider may have had an insurance status change in the intervening weeks. That's especially true in early January, when patients change health plans and don't think to tell their doctor's office.

2. Fewer days in accounts receivable: Fewer denials mean quicker payments, and because of the automation, Watauga Orthopaedics' number of days in accounts receivable went from 45 days from before implementation to 26 days overall now.

For some payers, that number is even better: 18 days for Medicare, 14 days for Blue Cross Blue Shield, and 10 days for Humana, she said.

"In private practice, that's massive," Wishon says.

3. Staff are freed up: Gone are the days of the employee with "Post-It notes stuck all over her computer screen" to keep track of payer changes, Wishon says. The tool is constantly and automatically updated to keep track of payer changes.

Thanks to the automation, Watauga Orthopaedics eliminated its eligibility department.

Now, the employees that were doing that work manually were moved to more patient-centric roles. One of them works in check-in/check-out, one is on the appointments team, and the other does all of their attorney requests for disability records, says Wishon.

4. Shorter wait times for walk-in patients: Because insurance checks are automatic, patients get in to see a physician more quickly.

It all helps Wishon on her quest to eliminate as many busywork, backend jobs as possible.

"I have put more resources on the front end," she says. "We need more patient-centric people. We need face-to-face people."