September 19, 2018

Optimizing Real Time Eligibility with Epic

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Many errors in the revenue cycle can be attributed to not selecting the appropriate insurance plan during registration.

One recent presentation at the annual NAHAM conference cited that 20% of registration-related denials were due to coverage and Real Time Eligibility (RTE) related issues. RTE can present unique challenges to an organization because it sits at the intersection between technology (both from your own EMR and a vendor partner) and operational process. RTE is also often an area that gets tagged as “optimization” during the initial implementation phase, only to not get re-addressed later on.

Over the next several weeks, we’ll be focusing on several of the topics below with the ultimate goal of helping you do the following:

  • Increase RTE Automation
  • Decrease Eligibility Related Errors and Denials
  • Increase Front End Payment Collection
  • Optimize RTE Processes
  • Decrease Payment Variances

Below are some key focus areas for real time eligibility. In two weeks, we will do a deeper dive into how optimizing your benefits filing process can increase front end payment collection.

  • Enabling Plans for RTE– First things first! In order to take full advantage of an automated RTE system, you need to have as many payers enabled for RTE as you can. Most RTE vendors offer hundreds of payer connections including large commercial and local payers. Work with your RTE vendor to make sure that at least 90% of your claims volume is processed through real time eligibility
  • Plan Mapping and Auto-Creation of Insurance Plans– Selecting the correct insurance plan is a critical initial step in the revenue cycle. You can configure Epic to automatically recommend the correct insurance plan based on information returned in the response so that end users don’t need to choose from a list. You can also automatically create the coverage which requires no end user intervention.Although you can do this configuration in Epic, RTE vendors will also offer a service to do this mapping for you to minimize IT resource concerns.
  • Benefits Filing and Payment Collection – Filing benefits information is instrumental in calculating accurate estimates and collecting payments on the front end. Most RTE vendors will offer a service that standardizes benefit data returned in the response to facilitate the set up for filing this information. At a minimum, you should be automatically filling all data points that can be used to calculate an estimate so that end users don’t need to dig through the RTE response to manually enter correct benefit information.
  • Self-Pay Process – Most eligibility vendors will offer a service to scrub self-pay patients and try to find government or commercial insurance. Its important to develop a comprehensive process for when to scrub this patient population to maximize efficiency and reduce RTE vendor costs. Although these transactions can be costlier, they often pay for themselves in the long run as they decrease overall self-pay volumes and end user intervention.

The Wilshire Group has unique experience with Real Time Eligibility optimization. We understand the right questions to ask to get the most out of your RTE vendor and out of Epic. If you are struggling with any of the above or want to talk about RTE please reach out to Matt Perron and Freeman Jenkins.

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