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COVERAGE DETECTION

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with better coverage detection

In the wake of the COVID-19 pandemic, an estimated 48 million people1 in the U.S. (under the age of 65) lost their jobs. This spike in unemployment caused many people to lose employer-provided health insurance as well.

About 20% were insured through their employer and more than 30% had coverage through Medicaid, CHIP or another family member’s job.

While it’s expected millions of these individuals and families will remain uninsured, many will enroll in ACA, secure coverage through a new employer or become eligible for Medicaid or other public programs.

What patients are up against2

  • Roughly 157 million people in the U.S. are covered by employer-sponsored plans.
  • Insurance premiums are increasing faster than wages. In 2020, premiums increased by an average of 4% while wages only grew by 3.4%.
  • 83% of insured workers have a deductible that must be met before most services are covered. 26% of those with an individual health plan have a deductible of at least $2,000.

What healthcare providers are facing

  • Loss of coverage on this scale has a major effect on healthcare providers’ bottom lines. Much of what is owed by patients is never realized.
  • CMS reimbursement rates are down 10% for some specialties, making it more important than ever for providers to maximize patient payments.
  • The specialties most affected by these cuts are those that perform in-office procedures or provide non-patient facing services: Anesthesiology, radiology, pathology, therapy, cardiology and more.

What can providers do?

We recommend taking proactive steps to find hidden insurance coverage among patients who present as self-pay—so you can collect more from patients and payers alike, limit bad debt and improve financials.

Why you're missing billable insurance coverage

A surprising percentage of self-pay and charity care patients actually have full or partial coverage that they’re unaware of. One reason for this: Payers can’t easily share coverage details with patients or providers, and plans are increasingly complicated and ambiguous. This lack of transparency is compounded by other factors that make it difficult for providers to capture accurate insurance information. Here are some typical scenarios.
Surprise billing
Legislation prohibits charging patients for a remaining balance on services rendered by an out-of-network provider without their consent. Accurate coverage information allows your practice to obtain consent at the time of service, and prevents holding a patient responsible for an inaccurate out-of-pocket amount.

Emergency room visits + arrival by ambulance
Per EMTALA requirements, a patient must be screened and stabilized before a facility can inquire about payment or their insurance status. A patient may be unconscious or in a life-threatening state. Many patients don’t carry their insurance card. Some uninsured patients use the emergency department for primary care, knowing they can’t be turned away.

Patient confusion
Several million patients lost or changed coverage during the COVID-19 pandemic due to significant changes in employment or income. Patients with new employer based coverage may not know which carrier they’re insured by or may have not received the specifics of their coverage. In other cases, patients may be newly eligible for Medicaid, COBRA, or worker’s compensation.
Retroactive Medicaid
Patients are eligible for retroactive Medicaid coverage for up to three months before they apply—if they met eligibility requirements at the time when care was rendered.

Dual coverage
One may be unaware that they’re covered by more than one insurance company or government entity. Many patients have secondary and tertiary insurance.

Charity care
Patients with high deductibles and copays may withhold insurance information to try to qualify for charity care.

Disability
Those on disability must complete extensive paperwork to get coverage.

Worker’s compensation
Patients covered by worker’s comp may provide their employer’s insurance information instead of their own, which can delay payment.

The impact of missing or hidden coverage

49_percent_callout.jpgTracking down missing or unknown insurance coverage is costly and time-consuming and can involve multiple touches throughout the revenue cycle.

On the front end, patient access staff try to verify coverage before scheduled appointments. If they can’t, the accounts are written off, in-house collection processes are initiated or the accounts are outsourced to a third-party collections firm. After all this, nearly half of patient responsibility is written off as bad debt, which can really hamper cash flow and leave patients frustrated.

Four ways to find insurance for self-pay patients

True self-pay patients generally pay about 6% of what they’re billed, while “self-pay after insurance patients” or those with high-deductible plans pay roughly 15.5%. To realize more revenue, many providers are willing to invest in processes that can help uncover hidden insurance. Here are some common approaches.

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Select the right coverage technology to meet your organization’s needs

Without the right technology, searching for active insurance coverage among self-pay patients can be like looking for a needle in a haystack.

Waystar’s Coverage Detection solution can help you overcome many of the challenges listed above by deploying powerful financial intelligence based on 15 years of data from payers and a wide range of provider types. Our proprietary technology identifies active and inactive coverage—no matter where patients enter the system—and routinely finds 5%-15% of billable insurance, which is nearly three times more than other vendors.
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How Coverage Detection works

Waystar_CoverageDetection_Monitor.pngSTEP 1: IDENTIFY HIDDEN COVERAGE

Our data intelligence engine finds hidden coverage by combing through millions of patient attributes and billions of transactions across the healthcare continuum. Users can request information during patient access or send batch files ahead of time for new self-pay patients or patients with scheduled appointments. Files can also be processed later in the revenue cycle—to search for hidden coverage or help mitigate eligibility-related claim denials.

STEP 2: CONFIRM COVERAGE IS ACTIVE

Using proprietary algorithms, data mining and machine learning, our Coverage Detection tool leverages 1,700+ payer connections to confirm eligibility and aggregate valuable insights.

STEP 3: DELIVER RESULTS

Within minutes, our technology reports active and inactive coverage for all patients in question.


BENEFITS TO YOUR ORGANIZATION

  • Increased productivity: Eliminating manual processes saves time.
  • Lower costs: Collecting from patients is about two times more expensive than collecting from payers.
  • More control: Resolving self-pay accounts in house eliminates the need to outsource.
  • Happier patients: Patients will be glad to know they have coverage they weren’t aware of and billing teams can avoid trying to collect from patients mistakenly identified as self-pay.
  • Higher revenue and profit margins: Improved collections reduces bad debt and inappropriate charity write-offs.
  • Fewer AR days and better cash flow: Identifying active coverage sooner allows for quicker, more complete collections.
  • Easy, cost-effective implementation: Like all Waystar solutions, Coverage Detection is cloud-based and requires no software installation or hardware upgrades.

whitepaper_thumbnails.pngMaximize self-pay revenue with better coverage detection

WHAT’S INSIDE
  1. Why you’re missing billable insurance coverage
  2. The impact of missing or hidden coverage
  3. Four ways to find insurance for self-pay patients
  4. Select the right coverage technology to meet your organization’s needs
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