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Medical Group Management Association

Implementing a Comprehensive Patient Clearance Process to Proactively Address Patient Responsibility and Support Price Transparency

Fellowship Paper - September 14, 2021

Paola Turchi MSHCA, FHFMA, CPC, FACMPE
PROJECT SUMMARY

There are two key drivers to implement a comprehensive patient clearance process at every practice. The first driver is the fact patients are now responsible for paying higher out-of-pocket expenses to cover their medical care. Historically patient payments represented 5% of a medical practice’s total revenue, but in 2014, due to higher adoption of high deductible health plans (HDHP), this percentage increased to 15%, and in 2018 it increased to 35% (Wixom, 2019). Although this trend has highlighted the importance of implementing processes to proactively check benefits and collect from the patients, there are still medical practices that do not consistently verify insurance information, only collect copayments at the time of service, and leave all other collection efforts to after the patient has left the office.

The second driver is the hospital price transparency rule signed into law in 2020. Although hospitals are the only entities required to proactively share their pricing information with their patients, starting January 1st, 2021, patients are going to expect the same type of information to be available for their medical providers.

This business plan addresses how Patient First Urology can implement an initiative to proactively address patient responsibility and support price transparency in two phases. The first phase, which is described in detail in this document, will concentrate on leveraging current resources and streamlining front office and scheduling processes to include capturing accurate demographic data, checking eligibility and benefits, obtaining prior-authorizations (if applicable), estimating the patients’ out-of-pockets expenses, communicating payment expectations to the patient, and collecting pre-payments (if applicable).

The second phase of this project, which will be defined and documented after the first phase has shown positive results, will ideally include robotic process automation (RPA) and mobile check-in features so the practice can further (1) increase time of service collections, (2) increase the practice’s clean claim ratio, and (3) reduce labor costs.


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About the Author

Paola Turchi MSHCA, FHFMA, CPC, FACMPE
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