How a 100+ location Ophthalmology Group solved complex billing issues and created price transparency while saving over $1.3 Million in labor costs and navigating the erratic fluctuation trends of IPAs in California.
A CA Eye Conglomerate was able to scale to over 100 practice locations and save over $2 Million per year by entrusting their eligibility verification processing to pVerify, avoiding costly expansion and retraining of billing and front office staff.
The front office verification staff for one of the largest vertically integrated eye care groups in the country faced huge eligibility verification challenges due to the complexity of the California market, with its mix of payers, Independent Provider Associations (IPAs.) and other managed care organizations. California has the highest percentage of any state population covered by HMOs and IPAs, with capitation IPAs playing a big role in benefit determinations. Insurance is designed with patient financial considerations as a priority, which often puts providers in complex benefit determination scenarios. Just getting the right payer on the phone is a huge challenge, while manually navigating multiple websites, making phone calls, and using disparate logins creates inefficiency and often leads to verification errors.
IPAs allow a patient to change associations as they please – with no time, location, or financial restraints. The unfortunate outcome of such flexibility lies in the rules of the IPAs themselves – only a provider participating with an IPA will be paid for services provided. When a patient hops from one IPA to another – they are not required to tell their doctor, resulting in unexpected denials and daunting billing follow-up. Quite often a provider discovers their patient is no longer in their associated IPA – leaving them stiffed for the services rendered with no avenue to seek payment.
To further complicate the matter, the standard eligibility software solutions available to CA Eye were only able to verify a patient’s first level of coverage. After that, a second level of verification was required to verify the MCO/Plan Sponsor and discover a patient’s current IPA selection. Some clinics required a third level of verification to identity the IPA benefit details and capitation limits.
Beyond the IPA challenges, CA Eye was forced to contact payers directly, 40% of which were dedicated Vision Payers, requiring manual logins to individual payer websites, as no vision payers have electronic interfaces. Without an all-in-one portal, staff had to deal with multiple logins and passwords for each of their locations.
When coming to pVerify, Inc., CA Eye had 3 primary initiatives–
(1) Identify a patient’s current IPA affiliation and/or plan change which included discovering 2-3 levels of coverage to determine current IPA and comparing results – current vs prior.
(2) Identify a more efficient way to verify Vision Payers without manual entry.
(3) Automate all processes to remove staffing constraints, cost, and human error.
The manual effort of validating each patient’s benefits caused increases in staffing costs, time, and errors. Prior to each patient visit:
- 14 verification staff were responsible for logging into CMS, Medi-Cal, VSP Vision and other payer websites to identify each level of coverage for over 35,000 patients each month.
- Following the initial verification for IPA patients, the employee navigated to and verified the MCO, HMO, Plan Sponsor in order to identify the IPA listed in the current coverage.
- Making note of the IPA listed, the employee compared the current IPA to the IPA on the patient record in the EMR.
- If the IPA had changed, the employee determined if the provider of the upcoming service was participating with the new IPA. If not, the patient was required to self-pay or the appointment was canceled, at which time a loyal patient and potential revenue were lost.
From our initial introduction in 2018, pVerify’s Ophthalmology Patient Verification Solution custom Business Rules and Eligibility APIs could manage the multi-level verifications, relieving the burden of excessive data entry and collection. At first robust APIs were put in place but pVerify identified the client’s complex eligibility verification needs required more than standard APIs could handle, thus a custom-crafted Human-Enabled AI with a Quality Control system was implemented into the solution.
- In 2018 pVerify’s CTO Robert Dejournett initiated patient extraction and write back to CA Eye’s EMR but the Eligibility output via API required modification, as the client desired quick decision-making info to help the front-desk staff to attend to patients, to have transparency for pricing, and to complete an immediate review of IPA status. Thus, a change from real-time API to First-Class Batch provided the client with all the information required, while avoiding extended processes as human-enabled AI automation was designed.
- As part of this process, pVerify extracted appointment data for the upcoming 11 days, then prepared the existing benefits and data for multi-level verifications, then accomplished a deep analysis of the results, with human-enabled RPA Bots, in order to identify several critical items: Medicare coverage and MA Plan Change, Patient changes to HMO, Medi-Cal Coverage with MCO/Plan Sponsor Name, IPA Coverage with IPA Change, Primary Care Physician Name and Date, Vision Benefits, etc, and Standard Benefit Details.
All critical information was returned daily in (1) a CLEAN Report for all patients that were verified, and no issues or changes were found. These CLEAN patient results were directly updated in the EMR record for staff to easily review the necessary information required to make time-sensitive decisions. Each response included a URL link to redirect staff to the patient’s full verification record in the pVerify Premium Portal. Additionally, pVerify generated a custom (2) Issues and Exceptions Report for patients requiring further attention. The Issues Report included patient records with incorrect or missing information that needed to be corrected as well as an inserted note from CA Eye’s Knowledge Base, powered by pVerify’s Business Rule Engine, to identify the types of patients that required further assessment.
- With 40% of the patient base consisting of non-EDI Vision Payer coverage, to complete the work in the most efficient way with less error, pVerify created multiple automation to verify Vision Payers and extract the benefit and materials coverage information, reassembling and returning it in a mock version of a standard EDI verification.
Batch Processing of appointment schedules is not unique in the industry, but the standard batch was not enough to accommodate CA Eye’s Verification needs. pVerify’s First-Class Batch takes batch processing to the next level by combining automated verification with human oversight, RPA Bots, machine Learning, and Human-enabled AI. In order to cover the max number of appointments, pVerify began pulling each DOS twice. The first parameter was five to seven days ahead, while the second was prior to two days from DOS, pVerify then extracted and filtered add-on patient appointments, since the initial extraction, and verified them as a separate batch. Because of the additional patient capture, pVerify returned 4 reports daily: CLEAN and UPDATED CLEAN for the front desk staff to have easy access to patient benefits, as well as ISSUES and UPDATED ISSUES for the Billing specialist to review in order to fix the coverage related issues. Only the CLEAN patient records were updated into their EMR Account.
By relieving the strain of educating high-turnover staffing positions and drastically reducing revenue at risk, CA Eye has experienced an ROI of well over $2 Million per year via pVerify’s unique and custom approach to patient benefit verification. This has allowed CA Eye to pursue their larger business strategy of growth through acquisition, leading to huge market share gains.
Regarding captured revenue at risk, 15% of CA Eye’s patient’s volume were identified and flagged by pVerify to prevent potential denials. With services ranging from $40 office copays to 20% patient responsibility of a $3000 surgery, pVerify’s Actionable Issues Report was estimated to prevent between $600,000- $900,000 in denials every month.
Director of Client Experience
The leader in real-time Healthcare APIs for Eligibility, Claim Status, & DME Solutions championing the highest level of benefits parsing with consumable API endpoints, expert developers to stride forward to refine and maximize benefit reporting, and next-level integration with our Business Rules Engine and scalable and seamless infrastructure including Medical, Dental, and Vision APIs. pVerify is a unique service-oriented healthcare company that focuses on value-added solutions, including the Ophthalmology Patient Verification Solution, for ambitious health and wellness providers. We shine in the industry for unparalleled hands-on support, excellent development tools, and a pre-and post-development foundation unrivaled as a service-oriented partner – NOT just another technology company.