The Denial You Could Catch At Intake

We’ve all seen this one before. A new referral comes in, and the patient reports traditional Medicare. Your intake team has no reason to doubt it. The visit gets scheduled; care begins, and the inaccurate claim goes out weeks later.

Then, the claim comes back as denied due to patients that had switched to a Medicare Advantage plan months ago without notifying the provider.

I hear versions of this from billing teams all the time. Other examples might include, patients change plans during open enrollment; a family member finds a cheaper option, or a card gets left in a drawer. Unfortunately, for your billing team, the result is the same. An accurate claim goes to the wrong payer, and revenue stalls while someone tracks the cause and solution of the denial.

The most preventable denial is also the most overlooked

Post-acute billing teams name their biggest denial drivers as missing or invalid claim data, prior authorization and eligibility verification. Across all care settings, insurance eligibility and benefits verification is the most frequently named top contributor to denials, according to Inovalon’s survey of more than 400 revenue cycle leaders.

As 63% call claim denials a significant revenue cycle challenge, only 54% of post-acute organizations are focusing on a closer monitoring of eligibility changes to prevent denials. The pressure is building where coverage changes most, with denials for Medicare Advantage claims rising 55.7% from 2022 to 2023, according to the American Hospital Association.

That gap is the opportunity. Eligibility problems are easy to fix before a claim is submitted and expensive to fix after it’s denied.

Why it’s getting harder, not easier

With the growing share of Medicare beneficiaries enrolling in Medicare Advantage, each plan change is a risk for your records to fall out of sync. Add in payer rule changes, Medicare Beneficiary Identifier (MBI) updates, and staff who are already stretched thin, a one-time initial check at intake isn’t enough.

What catching it early looks like

I walked through this exact scenario in a recent webinar with KanTime. Through the KanTime and Inovalon partnership, that check happens through integrated workflows.

In the webinar, I ran an eligibility check for a patient who reported traditional Medicare. The response came back with demographic details as well as an “other plan detected” icon. A closer look indicated an active Medicare Advantage plan.

From that same screen, I ran a second request against the new payer. No logging out. No second portal. Just the answer, in the moment, before any care was billed.

Your intake team can confirm coverage in real time for a single new patient or run batches across many patients and payers at once.

Coverage changes don’t wait for intake

The harder problem is the patient who was verified correctly at admission and switched plans later. That is where recurring checks pay off. With Inovalon’s Eligibility Verification™ solution, your team has multiple opportunities to verify coverage changes:

• Scheduled batch runs. Set eligibility to run on your preferred schedule. Many home health agencies now run biweekly, especially Medicaid; others run monthly.
• Run it early. I recommend 4:00 a.m. Not all payers automatically update at midnight, and an early run means results are waiting when your team logs in.
• Change reports. Results show active, inactive, and other-plan-detected patients, plus an icon for anyone who has changed payers since the last run.
• MBI change alerts. Eligibility now flags MBI changes, which have become more common after recent Medicare data breaches.

MBI changes catch more people off guard than you’d expect, and patients don’t always know their unique number. If your team is counting on patients to report a new MBI, those changes will slip through.

The goal is to identify the eligibility problems pre-adjudication, while the claim can still be fixed, instead of post-adjudication to reduce delayed or lost revenue.

The takeaway

The everchanging chase of eligibility is expensive in time and lost or delayed revenue. Inovalon prioritizes the importance of correct eligibility even in the clearinghouse. Inovalon’s Claims Management Pro™ also scrubs every claim against payer rules before it is released to the payer, so the clean claim reaches the right payer. Verify coverage at intake, keep verifying on a schedule, and act on changes before the claim goes out.

Watch the full webinar: Connecting Claims Management Across Every Payer for Home Health and Hospice

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