Discovering Missed Health Insurance Coverage: The 3 Most Common Types

nThrive insurance discovery tools for healthcare revenue cycle

In 2020, 47% of hospitals saw increases in bad debt and uncompensated care.1 Incomplete or inaccurate patient demographic information, an unverified primary payer, resource constraints and more contribute to this deficit. At a time when margins are tighter than ever, it’s critical for healthcare organizations to get fully reimbursed for care rendered. Identifying active, hard-to-find coverage at the point of care can make a big impact on your bottom line.

While many revenue recovery efforts can be done successfully through in-house processes, an experienced partner can help your team realize reimbursement opportunities that are often missed.

Read on to learn the three most common sources of missed coverage so you can take steps to combat them.

1. Self-pay

A patient who presents without insurance or doesn’t disclose any potential insurance coverage at the point-of-service is considered self-pay. This type of account typically drives the most uncompensated care for a hospital and is the best place to start to look for missed coverage. And for good reason as up to 60% of hidden coverage comes from self-pay accounts.

2. Medicaid secondary

Due to Medicaid Expansion and the Affordable Care Act (ACA), it is now more common for patients to have more than one insurance provider. In cases where a patient has Medicaid and another insurance (commercial or Medicare), Medicaid will always be the secondary payer. Even as a secondary payer, Medicaid can represent valuable fee-for-service and cost report revenue.

Specifically, Medicaid secondary can:

  • Generate additional dual-eligible bad debt opportunities (paying $.65 per $1.00 of the patient balance)
  • Pay co-Insurance and deductibles for Qualified Medicare Beneficiaries (QMB)
  • Drive additional Medicaid Disproportionate Share Hospital (DSH) days to the cost report

3. Coordination of benefits opportunities

Coordination of benefits is needed when patients have more than one insurance plan. As mentioned above, the ACA created more scenarios where patients have both Medicaid and either Medicare or commercial insurance. In order for the claim to be properly paid, the correct primary and secondary payer need to be identified. Not identifying the appropriate primary payer can be costly, especially as timely filing deadlines come into play. For this reason, potential coordination of benefits opportunities need to be found as early as possible.

Commercial plans represent the greatest reimbursement potential, as 50–60% of the billed revenue (“sticker price”) for care is covered by a commercial plan, compared to 10% covered by Medicaid.

Contact us today and learn how nThrive’s insurance discovery solutions can help you identify hard-to-find coverage and maximize your organization’s recoveries.

Source

  1. Kaufman Hall 2020 Performance Improvement Report

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