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Why Eligibility Matters in Health Care


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Multiple forces are driving the need for more timley, accurate and
thorough eligibility verification.

The declining number of Americans with employer-sponsored health insurance since 2000 has been documented by the Kaiser Family Foundation in its study Health Insurance Coverage in America: 2004 Data Update (November 2005). In addition, those Americans who do have employer-sponsored plans are changing employers more frequently; as a result, their benefit plans are also changing. Insured patients are facing higher deductibles, copayments, and coinsurance levels, and those amounts are often changing annually at open enrollment. In response to cost concerns, many plans are offering reduced benefit coverage.

Also, restricted networks are now tiered, making coverage determination more complex. Although the Health Insurance Portability and Accountability Act requires health plans to support a standard electronic eligibility inquiry, the regulation has failed to meet provider needs. For example, HIPAA requires health plans to answer only “yes” or “no” in response to a provider’s eligibility inquiry, falling far short of all the information needed by providers. For those plans that provide additional data, the lack of standardization makes communication with multiple plans difficult. Health plans’ differing patient identification requirements also add to the difficulty of confirming eligibility.

Finally, standard business requirements for electronic commerce, such as acknowledgment of inquiries or timeliness of expected response, are not addressed by the HIPAA requirements. The ripples affecting providers attempting to verify eligibility are widening. Software vendors cannot offer seamless eligibility verification solutions without health plan cooperation. Providers have few cost-effective options. And semi-automated solutions such as web site lookup or interactive voice response continue to consume staff time



By Phoenix Services Managed Care Consulting, Ltd.
Healt Care Consutants and Advisors
ABOUT THE AUTHOR: Pam Waymack, FHMFA, MBA and Gwen Lohse
Pam Waymack, FHFMA, MBA is recognized for her expertise in bridging the gap between contracting and getting paid under managed care. She has consulted to over 100 organizations over the past thirteen years including providing expert witness support to attorneys and their clients.

Pam is the lead author of Denial Management: Key Tools And Strategies For Prevention And Recovery published by hcPro in 2005. She is a frequently requested speakers nationally on current issues in payor contracting including slow payment, low payment (underpayments and silent PPOs) and no payment (claim denials).

Prior to consulting Pam held senior management positions at Children’s Memorial Hospital, Northwestern Memorial Hospital, The University of Maryland Medical Center and Johns Hopkins Hospital for over 15 years. She is a fellow of HFMA and holds an MBA in Health Care Administration and Finance from the University of Chicago and a BA in Economics from the College of William and Mary.

Copyright Phoenix Services Managed Care Consulting, Ltd.

Disclaimer: While every effort has been made to ensure the accuracy of this publication, it is not intended to provide legal advice as individual situations will differ and should be discussed with an expert and/or lawyer.For specific technical or legal advice on the information provided and related topics, please contact the author.

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