4 Ways to Detect Changing Patient or Resident Insurance Coverage

Changing employment status, choosing a new plan during open enrollment, joining a family member's insurance plan - these changes and more can prompt someone to switch insurance coverage. In fact, it's estimated that 15-20% of Americans change their health insurance plan each year.[1] But if providers have outdated patient or resident information, the organization's reimbursement - and potentially the patient's or resident's access to care - could be at risk.

For healthcare professionals, that makes insurance coverage detection especially important. Having accurate insurance information for patients or residents reduces denials and keeps revenue flowing. It also helps prevent delays in care and minimizes individual financial burdens.

4 ways to maximize healthcare coverage detection

1. Verify coverage early to prevent billing surprises

One of the most important best practices for ensuring accurate coverage is to verify coverage early, in advance of scheduled care. Before care begins, staff should check that patient or resident demographics and insurance information are up to date in the records system. Then, the organization should reach out to the insurance company to verify coverage, make sure required authorizations for care are in place, and determine the individual's financial responsibility for care.

For healthcare organizations, verifying coverage prior to scheduled care can protect revenue by preventing denials due to incorrect patient information, missing authorizations, or changes in coverage. For patients and residents, verifying insurance coverage early can provide a seamless experience by preventing delays in care or surprise bills as a result of outdated coverage information.

1. Automate verification to reduce redundancies

While coverage detection for changes in benefits is essential to keeping an organization's revenue cycle secure and providing timely care, healthcare coverage detection can be time-consuming and costly. One HIMSS survey revealed that healthcare organizations spend nearly 110 hours per week and have 10 employees dedicated to patient identity and coverage detection.[2] To save time and money, organizations can automate coverage detection. With automation, staff can identify previously unknown coverage for multiple patients or residents at once. Automation also can detect healthcare coverage from additional sources that individuals may not have reported.

Furthermore, with automation, providers can streamline coverage detection for changes in healthcare benefits, saving staff time. Plus, it can save the organization money, with manual coverage detection costing approximately $7.32 per insurance verification compared with $2.73 per check with automation.[3] With a facilitated workload, staff can reduce redundant work and devote their time to critical billing issues. That increased efficiency can save staff costs, as some hospitals report they have as many as 20 full-time employees dedicated to resolving denials, according to the Inovalon April 2024 survey.

1. Verify Medicare and supplemental coverage to improve cash flow

Older Americans are especially prone to changes in medical coverage, due to switches from private insurance to Medicare coverage and to the many options available for Medicare supplement plans. In 2023, more than 65 million Americans were enrolled in Medicare.[4] Of those who are 65 and older, 52% are covered by more than one health insurance plan because of available Medicare supplements.[5]

For residents or patients who are covered by Medicare, coverage detection becomes especially important. That's because it's possible for many covered by Medicare to make changes to their plans at any time of the year, not just during open enrollment. Coverage detection for changes in benefits can reduce costs for these patients and residents, and prevent a delay in care that may occur because of outdated insurance information.

1. Protect patient access with healthcare coverage detection

Coverage detection for changes in benefits is crucial to reducing denials and protecting the health of the revenue cycle. But healthcare coverage detection is also important to ensuring a quality patient or resident experience. With healthcare costs serving as major concern for the majority of Americans - and as a barrier to care for 9%, as reported in one survey[6] - coverage detection can help ensure that patients and residents are receiving their full benefits to reduce their out-of-pocket costs. It also can help prevent delays or cancelation when inaccurate benefits information triggers a denial. In short, accurate healthcare coverage detection facilitates care and a positive experience.

With employer-provided healthcare plans, increasing Medicare coverage, and expanding options for Medicare supplements, health insurance coverage changes are common - and a frequent event that providers must navigate. That's why having a solid plan to detect coverage changes in benefits is fundamental for protecting an organization's revenue cycle and delivering a positive care experience. Discover how Inovalon's front-end RCM solutions can help your organization stay on top of coverage detection.

1. "Large portion of people who leave their insurance plan re-enroll at a later date, study finds," Schnettler, Tim, Vital Record, Texas A&M, March 15, 2022, https://vitalrecord.tamhsc.edu/large-portion-of-people-who-leave-their-insurance-plan-re-enroll-at-a-later-date-study-finds/
2. "New Perspectives on the Patient ID Problem in Healthcare," Krzepicki, Amanda, MPH, HIMSS. Accessed February 7, 2024. https://patientidnow.org/wp-content/uploads/2022/11/PIDN-Research-Findings-Final.pdf
3. "A Decade of Progress," 2022 CAQH Index, accessed February 22, 2024, https://www.caqh.org/sites/default/files/2022-caqh-index-report%20FINAL%20SPREAD%20VERSION.pdf
4. "Medicare Enrollment Numbers," Center for Medicare Advocacy, June 29, 2023, https://medicareadvocacy.org/medicare-enrollment-numbers/
5. "About 42 Million People in the U.S. Had Multiple Health Plans in 2021," Mykyta, Laryssa; Keisler-Starkey, Katherine; Lindstrom, Rachel; Bunch, Lisa; United States Census Bureau, July 19, 2023, https://www.census.gov/library/stories/2023/07/multiple-health-coverage-plans-in-2021.html#:~:text=About%2043%20Million%20People%20in%20the%20U.S.%20Had%20Multiple%20Health%20Plans%20in%202021
6. "Health Insurance Facts and Statistics," Masterson, Les, Forbes Advisor, August 8, 2024, https://www.forbes.com/advisor/health-insurance/health-insurance-statistics-and-facts/

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