Eligibility & Benefits KPIs Every Healthcare Practice Must Track

Is your practice tired of wrestling with insurance denials, deciphering EOBs, and watching your revenues flip through the cracks? You are not alone. Welcome to the Claim Game, the podcast designed to cut through the confusion and provide you with the best practices for revenue cycle management success. We are Jeremy and Katherine Zug, and we've been with people just like you in the trenches. Each week we'll break down complex billing processes, share real-world solutions from practices like yours, and ask questions of the game makers and changes of health care so you can take control of your revenue. Let's turn those claim denials into deposits and help you return to focusing on patient care. It's time to win the Claim Game. Hi, everyone. Welcome back to the Claim Game. I'm Jeremy Zug, and as a reminder in this season of the Claim Game, we're going through the revenue cycle management best practices. One domain, one territory at a time, and the last time we talked, we discussed steps three and four of eligibility and benefits, which are updating accumulations and communicating with patients. And remember, these are key domains. These are important, they need to be addressed and managed in your private practice, and mastering each one is really important to make sure your revenue cycle management, your billing, is a revenue engine for your practice. So we're going to be grabbing a magnifying glass. We're going to zoom in on each of these domains in great detail. We're going to give you winning strategies to navigate a very complex system that we exist in. Similarly, you're going to claim victory for your practice's bottom line. Quick reminder, if you missed the initial setup and you want to understand the full scope of the board of how the six domains of billing work together, be sure to check out episode one for the complete overview. It gives you a really high level, I know it's kitschy, but 30,000 foot view of how billing works together and each domain. So go back, check that one out, otherwise we're going to keep moving forward. And today we're going to talk about eligibility and benefit key metrics. So I want you to think if you ever had a patient angry at you because of something that their insurance company did. If there was a group of you here, you're probably nodding along, actually, when I describe that scenario. And if you've been in private practice for any amount of time, you've seen that either from a supervisor, a colleague, you yourself have seen that, but now think if that patient didn't care whose fault it was, all they knew is that they got a bill they weren't expecting. And that right there is the experience of trust leaving your practice. And usually it's followed by revenue leaving your practice. So our goal today is to give you the measurements and the tools you need to fix that specific problem. At the end of this episode, I don't want you to ever have a patient that comes back into your office and is mad about a mistake that their insurance did because we could have caught something earlier on in the process. Let's focus our attention on eligibility and benefits and key metrics. We're going to analyze each of its challenges. And I'm going to give you the optimal best practices to dominate this particular process. So here's a question. Why is it so important for you to track specific metrics for a process as seemingly straightforward as eligibility and benefits? What's the real advantage of using data here? Well, first of all, one of the resources you can never get back, you can't buy, you can't scoop up more of out of the ocean, is time and eligibility and benefits. Take it from me. As Catherine and I, we've been doing this for a while, we have an amazing team at practice solutions and army of builders that do this process day in and day out. And let me tell you, this is an extremely time-consuming activity. It is one of the reasons why when practices call us, they come to us because they're doing a good job. They are rocking it. They are good clinicians, they have good systems, and it means that they have a lot of volume. What they find is that they have a high volume of eligibility and benefit check needs and nobody to do it. And they don't trust the little AI button that says, "Check the eligibility and pop something back at me." And that's a good idea to not trust that. So you want to track efficiency and make sure that your staff, if you're doing this in-house, is doing it really, really efficiently. If you're outsourcing it, you want to make sure that you're not paying for that time. Because if you're paying by the hour, for example, eligibility and benefits checks can easily get away from you. So you want to make sure your managing costs that way by tracking efficiency. Second, tracking eligibility and benefit metrics helps practices move from reactive to proactive problem-solving. What does that mean? Well, oftentimes you can catch things like carve-outs where an insurance company has subcontracted out a specific benefit to another payer. You can track that in eligibility and benefits. And instead of getting denials on the back end downstream where your billar is ripping their hair out, not me, I wouldn't rip my hair out, obviously, but they're really struggling. If we fix eligibility and benefits, we can be really proactive about catching those plans that are carve-outs. We can catch the insurance companies that are a pain to work with. And then you can make a long-term strategic decision about what to do with that payer. And finally, you can use that data to evaluate the performance of your staff. Not in a higher fire way, maybe they're doing something that bad, but really just to improve the accuracy of the information you provide to patients. One of the things we really value in practices that we work with or even internally among our leadership team is we want to improve. There's always something to improve. There's always something to fix. And I know for some of you that's the worst thing you could hear and for some of you that gets you really jazzed and excited, but we want to make sure that we're constantly day by day making progress on improving our systems and how we're doing what we're doing. So let's talk about some key metrics. I'm not going to make this complicated. Metrics can be in KPIs, oh my goodness, the amount of articles you could read on KPIs and KPIs management. I'm going to give you just a few. And these are the ones that I believe are the metrics that are going to communicate the reality of what's going on in your office, the quickest so that you can arrive at the best decision possible. So let's start with the first key performance indicator. That's what KPIs stands for if you didn't know. And it's the efficiency meter and it's the time to complete the eligibility and benefit. What is this? What is this track? Why is tracking time, time to completion so important? So essentially this is really easy. From the time somebody gets on the phone or in a portal with the right information, the right tools, right, patient ID, patient ID card, back the card, how long does it take them to get the right information, the first time start to finish, knows to tail. And that metric is going to measure over time, the average time it takes for your staff to complete a full eligibility and benefits check from the time of the request to the end of the check. And that metric really allows you to identify two, two problem areas, which payer is a payer of concern. Is there an insurance company that's really dragging their feet? Are they making this information particularly difficult to obtain? If so, you may want to consider where they fit in the lifecycle of your practice or which team members are causing delays in the process or even if your process is flawed. So you can make a decision about a payer, you can make a decision about a team member, you can make a decision about a process either way though, you're not sitting in your office angry about why aren't these getting done faster or more accurately. We can actually make a decision about what the next step is, what, why is this important to track? Some of those reasons might seem obvious, but I want to give you some of these, along eligibility and benefit completion time, can delay a patient's first appointment and create a negative first impression. And with some payers, this may be news to you, but some payers will negotiate rates based on how quickly a patient can get in to see a provider. You need to check with each payer you're in network with, but essentially insurance companies are, they're measured and their accreditation is determined sometimes by how quickly patients can get matched up with providers. And so what you don't want is the eligibility and benefit check process. If you have a pay raise based on this particular metric, you don't want eligibility and benefits to be a limiting factor, you want that to be quick and accurate the first time. The other reason this is important track, because eligibility and benefits can be a time suck for your practice, especially if you're seeing high time to completion for multiple employees for the same payer, you'll need to evaluate what the root cause of that is and fix that pretty quickly. The next question that I have for you is, or that you might have for me, rather, is how can a practice pull the data for this KPI? One of the problems that I have with KPIs generally, and my team knows this, is that it takes forever to data mine. And you might be asking, what does it imply if their average time is too long? So this information is actually tracked manually and possibly by different staff members. So this usually starts with your admin, right? Whoever completes or gets the patient inquiry or the intake information, you want to get the date of the patient intake, the date of the eligibility and benefit check requested, the date of the schedule appointment, the insurance company, and the insurance plan. Now, that's a lot to track. We'll talk about that a little bit more, and we'll give you some tools on how best to track this stuff. So that's the first thing you want to track. The second is, who's completing the eligibility benefit check? You want to date the eligibility, you want the date, the eligibility and benefit check was completed, and the employee name, and the rest should automatically calculate, right? So you know the time from intake to eligibility and benefit request. You get the time from the eligibility and benefit request to the eligibility and benefit check. You want to know, was that completed before the appointment was scheduled? Likely, you want to know if that was communicated to your patient. You want to know which insurance company and which employee. We have a tool that will help auto-populate a lot of that. So that is a rough skeleton of how you would track this particular metric. The items there will tell you some really important information. Do you have a long time from intake to eligibility and benefit check request? What's going on between, we get a patient inquiry, and the time the request goes out. It'll tell you if you have a long time from eligibility and benefit request to eligibility and benefit check, right? And usually that is a volume issue with a particular person, right? If they get a request, right, let's say you send me an eligibility and benefit check to complete, and it takes me three days. That's no good, right? You need a response pretty quickly, and so that's probably a Jeremy problem that could be a process problem, but you need to know that information. You also want to know if you aren't completing the checks before the first appointment. You do not want your patient to walk in the door and not know what they could possibly be paying. The last episode we talked a lot about that, and the tools that we can give you around communicating patient balances. You also want to know if your average for a single insurance company is relatively longer than others, right? And you also probably want to know, is the benefit check for that payer, that insurance company, longer than others, and what is their reimbursement rate? So you want to know if they have a low reimbursement rate and you are paying your staff's time to run an onerous eligibility check, I don't know if you're profitable on that. And so that should be throwing up some red flags for you almost immediately. And then you want to know if you have a staff member who takes longer than other staff members on the average, right? For a couple of reasons, one, you want people to improve. We've talked about that, but you also want to recognize high performers, right? Make sure you're saying thank you to people that are doing a good job. You want to recognize and reward people for good work. One of the worst parts of my job, seeing practices lose revenue. Not because of bad care, but because their notes didn't back it up. If you're billing insurance, you already know that your notes are your defense. So if your documentation falls short, clawbacks, appeals, and a whole lot of headaches feel inevitable. One of the best parts of my job, empowering our clients to focus on their practice. Not payer back and forth. A big part of that has been discovering Blueprint. An AI assistant purpose built for mental health care. In other words, made by therapists for the way therapists work. I've seen folks start using Blueprint to help with getting progress notes done faster. But it has turned into a game changer. Blueprint drafts compliant treatment plans, visit notes, and flags any missing clinical notes, which means fewer denials, cleaner claims, and faster revenue capture. Check the notes for the link to give Blueprint a try for free. All right. That's the efficiency metric. If your head hasn't completely melted by now, maybe take a break, get a hot beverage, and a pen and some paper we can talk more about the efficiency metric. But I do want to talk about the trust metric. This is important, and you can absolutely measure trust. Remember the analogy I used at the beginning of this episode where a patient blames you for something that the insurance company did? That happens all the time. But that's a trust issue, and we want to be able to measure the trust metric here with the insurance company. So, KPI-2, what does it measure? Why is accuracy for eligibility benefits so important? So, we are going to measure eligibility and benefit accuracy. And this measures the percentage of eligibility and benefit checks that correctly match the payment and patient responsibility information received from the payer after a claimist process. Now, if any of you listening have 100% accuracy rate, I'd love to talk to you because we have not been able to achieve that level of accuracy. But here's why eligibility and benefit accuracy is so important. High accuracy is crucial because it ensures that the patient is billed, the correct amount, which prevents billing surprises and the need to issue refunds or chase collections. Holy smokes, you've just saved yourself a ton of time and headache downstream. And low accuracy can lead to patient dissatisfaction, patient distrust, and create a lot of extra work for the billing team, the admin team, or even the clinical team, as they have to reconcile and correct incorrect patient balances. So, how do we pull the data for this particular KPI and what is a low accuracy rate imply about our process? This is an on-demand metric. Record them as you find them. The date of the discovery, the patient initials, the date of birth, the date of service, the issue, the eligibility of benefit reference number. That's really important in case you can fight that. Insurance company track the insurance plan and the employee. What calculates this data? You want account of the errors by insurance company and by employee. Now, what does this metric imply, a low accuracy rate may imply that the person completing the eligibility and benefit checks needs more training or that a specific payer might be providing misleading information. They're not perfect folks. I think we all can recognize and understand that insurance companies make mistakes just like anybody else. So, you want to know which payer makes more mistakes than others. You also may just need to investigate your process for the payer. But if it's not a payer problem, what if you're not asking the right questions or you're not looking the right spot in the portal? What if you have the wrong portal? What if it's the wrong plan? You might need to walk through that process yourself, ideally not, but you might need to in order to find out what the root cause of the issue is. And what I love about KPIs is it tells you exactly where to look. You have my dad ran a camp in Northern Montana for a long time. And there was a shallow part of this lake. One of the things I do in my free time is I would go look for prodads or crayfish or whatever people call them. And they're these big flat rocks under the water. And I knew over time which rocks to look under. I mean, not every rock is going to have a big juicy crodad under it. But some of the bigger rocks did. And so, that was the process of trial and error over several years. But if you know precisely where to look, you can solve this much, much faster. Thanks for indulging my story about this. Now we're going to get back to measuring eligibility and benefit tracks. The next metric you want to find, this is the final one. So there's only three metrics. And you want to know the eligibility and benefit call time log. How does this log help you? Well, the final KPI tracks a, it's a separate but related metric that tracks the time of your staff. And it tracks the time your staff spends on the phone with payers to get eligibility and benefit information. So while one metric tracks patient inquiry or intake to final result, this one tracks how much time are we spending, which payers require the most time and energy from your staff, which might be could be an indication of poor customer service or inefficient portals. But it also helps you identify a specific staff member is just taking longer than the average to get the information, which could imply additional training or resources needed. And how do you pull this data, right, what kind of actionable changes can you make based on this information? This is a periodic KPI that should be tracked maybe two times a year for a set amount of time, maybe two weeks time study. The data for this log is collected by the staff members who are doing eligibility and benefit checks. And it's really simple. They track the date, their name, the call length and the insurance company. That's it. Do that for two weeks. Once the predetermined time period is over for the time study, you'll have an average call length by insurance company. And this is only relevant then to companies for which you need to call and get an eligibility and benefit check. I think in our current age, well, the fact that we use faxes still blows my mind. But some payers don't have portals still. And so you want to know for the ones that you're calling how long does that take, what does that data imply? Well, based on this data, you may need to amend your payer list to remove a payer with a really long average call time. If the revenue, if the rate you're getting paid is not worth the administrative cost you're spending to get that information, right? I hope that hopefully that makes sense of it doesn't. Please reach out. We can talk you through that. You can also use this data to identify which payers offer the most efficient portals and director staff to use those methods whenever possible. All right. We talked about a lot of things, but I want to talk about a tool that we have developed and that you can have access to track this data. And it's called the eligibility and benefit KPI dashboard. And this is a comprehensive tool that aggregates all of the metrics we've discussed into one central spot. It provides you like a dashboard, a view of your eligibility and benefit process, allowing you to quickly spot trends and bottlenecks. And it helps you to make data driven decisions, not gut feeling. I have a hunch decisions about your eligibility and benefit accuracy and efficiency. So really the hope here is that your revenue cycle runs as smoothly as possible. And I told you about the last episode we talked about the big agency in Pennsylvania that had an eligibility and benefit issue. And when we implemented this for that agency, they were able to self manage their own eligibility and benefit process. And that's the best thing we could do for you is to help you empower you to manage this on your own or outsource it to somebody who's going to take it off your plate. You've got enough going on to track eligibility and benefit call times. But if you're big enough and that makes sense, we want you to be able to do that independently and make the best decisions you can. So today we talked about eligibility and benefit key metrics. We discussed the KPI dashboard again, that's available online through our Learning Hub, the Hourglass. And if you think it'd be helpful for your practice, check out the link in the show notes to the Hourglass. And the next time on the claim game, hopefully we'll have an interview with a game maker. And if not, we're going to keep chugging along through our best practices. But you won't want to miss it either way. We hope you have a great rest of your day, a great rest of your week. And we hope that this helps you to go out and win the claim game. Thank you so much. We'll see you next time. If you enjoyed today's episode of the claim game, please take a moment to leave us a rating and review wherever you listen to your podcasts. It really helps new listeners to find us. Make sure you never miss an episode by subscribing to the claim game on your favorite podcast app. Your feedback means so much to us. We want to provide valuable education about Revenue Cycle Management. So if there's something we didn't cover in our topic that was a burning question for you, please let us know so we can try to get you the information you desire. You can find the links to all resources we mentioned in this episode and the show notes. And if you want to dive deeper into our resources, we have two places you can do that. First, you can go to our blog at practicesl.com/blog where we have eight years of educational blogs. If you want to learn more about what practice solutions does, reach out. We'd love to hear from you. Just go to practicesl.com to learn more and to connect with one of our awesome people on our team. Thanks for listening. We are Jeremy and Katherine Zug and this is the claim game. See you at the game table next time.