Patient Access Management and Revenue Cycle

The Patients Access plays a very important role in capturing and collection of patient service revenue.

​Patients Access and a Successful Revenue Cycle Management
The Patients Access plays a very important role in capturing and collection of patient service revenue.

There are 3 parts of Revenue Cycle where the Patient Access Management is very important and the Patient Access Team plays a very valuable role.

1. Pre-service Phase

• Scheduling patients
• Pre-registering patients
• Verifying insurance coverage and eligibility
• Verifying pre-certification and referral requirement
• Discussing patient costs and providing financial counseling services if required

2. Time of Service 

• Activate the patients record in the Electronic Medical Record and or Practice Management system
• Attached copy of insurance card front and back on the patient's chart
• Attached copy of government issued identifications on the patient's chart
• Patient reviews and sign the consent forms
• Completed the positive patient identification
• Financial Clearance
• Patient Arrival
• Patient Care Delivery

3. Post-service Phase

• Claims Submission
• Patients Responsibility
• Claims follow up

Focusing on Customer Service and Patient Satisfaction is very important.

Customer Service and Patient Satisfaction
1. Treating patient with respect and dignity
2. Treating patient as you would want to be treated
3. Communicating in a manner the patient can easily understand
4. Value your patient's time and focus on efficiency
5. Show empathy to your patient

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What pieces of information do we gather:

• Patient's Name
• Address
• Date of Birth
• Primary Insured's name (Subscriber)
• Social Security number (Guarantor/Subscriber)
• The insurance company name
• The patient's insurance ID and group number
• Photo ID
• Copy of the primary and secondary insurance card (front and back)
• Subscriber's relation to the patient (self, spouse, child, other)

Additional Useful information that you can also gather from the patient:

• ​Patient's complaints (pain? injury?)
• Patient's Primary Care Physician (if applicable)
• Date of Accident? (for Liability Insurance such as Motor Vehicle and Workers Compensation)
• State where the Accident happened
• Name of the Injury Attorney (if available)
• Name of Injury Case Adjuster (if available)
• Name of Injury Nurse Manager (if available) 

​So what's next after obtaining all the necessary information?
1. Patient access team member must start confirming coverage for the patient
2. Verify if the provider is in-network or out-of-network with the patient's plan
3. Check eligibility if the patient is eligible for coverage on the date of service
4. Ask the patient if they have a secondary insurance coverage
5. Complete clarifying the benefits for services with the insurance company
6. Check the patient's copayment or any co-responsibility and if the patient has an out of pocket amount that has to be met (family or individual
7. You can ask the insurance company for specific benefits for specific services. I always suggest giving insurance company specific CPT code(s) or Diagnosis code(s) if available - document everything
8. Collect the copay at the time of service if you are contracted with the patient's insurance plan;
9. Verify if there is a deductible or coinsurance and how much have been met, you can collect them at the time of service as well
10. Make sure you be knowledgeable enough on how to answer the patient about their concern and questions about their copay or any other co-responsibility.

Let's look at how the Patient Access team verifies patient who has a Medicaid Coverage: 
Viewing a patient's ID card alone does not ensure their Medicaid eligibility, nor does having a referral or pre-certification on file. As a member of the Patient Access team, insurance can be verified during pre-service or on the date of service.

It is imperative in my opinion that the Patient Access team must verify eligibility during the MONTH that patient is scheduled to be seen or is coming for service. Because their coverage may always change. If you fail to verify eligibility, there is a very high risk of claim denial for sure. Possible scenarios? the patient may not be eligible at the time of service, or the HMO was not contracted with your practice at that time of service. Result? claim may not get paid. Resulting in lose of revenue. 

What happens if we did not correctly verify the patient identity?

• Medical error including the wrong medication, not knowing about their allergies and or the patient's blood type etc
• Claims denial resulting to non-payment for services from the insurer
• Poor patients outcome
• Poor patients experience since they will receive a bill for the entire cost of the rendered services

About 40% of data used for revenue cycle management are gathered by Patients Access Teams.

About 40% of data used for revenue cycle management are gathered by Patients Access Teams. Mistakes and errors will greatly affect the billing and coding process thus causing payments delay. Delayed reimbursement will significantly affect your cash flow.

Patients satisfaction, prompt payments are the best results of your high quality customer service and are all based on how good your team with their communication skills.