Practice Efficiency 

Going Beyond RCM: Why Patient Financial Clearance Matters

Written by
Kashyap Purani
Published on
January 8, 2024

What is Patient Financial Clearance and how is it different from Revenue Cycle Management? What can a healthcare practice do about it? Do you need modern Patient Financial Clearance tools? Read on to get an answer to all these questions.

Picture this scenario: a patient arrives at your clinic or facility, seeking quality care, only to find themselves entangled in a complex web of insurance terms (AMA reports 72% of patients report feeling confused by bills), surprise bills, denial of service, and frustration. This situation not only tarnishes patient experience but also punctures your practice’s revenue balloon.

In today's healthcare landscape, rising costs and complex insurance systems create a perfect storm for revenue cycle challenges. Collecting payments and navigating authorization hurdles can be a resource-intensive struggle for practices. Meanwhile, these inefficiencies cost healthcare practices an estimated $262 billion annually (Healthcare Financial Management Association). Patients, on the other hand, need help understanding their obligations and managing out-of-pocket expenses.

Enter patient financial clearance, a critical step often mistakenly conflated with the broader realm of revenue cycle management (RCM). But here's the rub: while RCM excels at post-service tasks like coding and collections-- it's backward looking and so does not address a lot of issues upfront. Patient financial clearance, on the other hand, shines by illuminating the path ahead. Think of it as pre-flight checks before takeoff, ensuring a smooth journey by eliminating potential turbulence – denied claims, billing surprises, and patient frustration.

So, why does patient financial clearance deserve its own spotlight? Because it is the difference between reactive scrambling and proactive control. Studies show it can increase point-of-service collections by up to 20%, reduce claim denials by 15%, and improve patient satisfaction scores (Healthcare IT News). Even more, robust programs can decrease bad debt by 30% and increase patient loyalty by 40% (Experian Health).

In this article, we'll unpack the unique value of patient financial clearance, unveil its distinct role from RCM, and share the knowledge to harness its power for a thriving revenue cycle.

What is Patient Financial Clearance?

Patient financial clearance is a proactive process that ensures smooth insurance verification, upfront cost estimation, insurance approval, and patient preparedness for their financial responsibility prior to receiving care. It is a bridge to ensuring that the patient gets the best care while navigating the financial terrain. Think of financial clearance like a well-lit roadmap before a hike, empowering you to make informed decisions and focus on your healthcare practice with clarity and confidence.

Patient financial clearance encompasses two key aspects:

1. Insurance Navigation:

  • Eligibility and Benefits Verification: Beyond confirming active insurance, providers delve deeper, verifying service coverage (based on CPT codes) and understanding relevant terms like deductibles, co-pays, coinsurance, and out-of-pocket maximums. It’s not just about getting this info, but also interpreting and applying this info at the point of service.
  • Prior Authorization: For specific procedures, obtaining approval from the insurer ensures reimbursement and avoids unpleasant financial surprises for both patients and providers. Understanding prior authorization needs can even influence procedure choices and subsequent payments. Even getting to know if a prior authorization is needed or not for a service is also useful in improving the patient financial clearance process.

2. Patient Responsibility:

  • Out-of-Pocket Estimates: Clear communication and, in some cases, collection of the patient's financial responsibility based on their insurance coverage is crucial. With high-deductible plans on the rise, providers cannot afford to neglect this revenue stream.
  • Price Transparency: The No Surprises Act and patients' growing expectations demand upfront cost information. Transparency builds trust and empowers patients while benefiting providers through improved collection rates and patient satisfaction.
  • Patient Collection Strategies: Upfront communication about cost estimates and, in some cases, partial or full pre-payment can significantly improve patient collection and reduce no-shows, a win-win for both parties.

Why does Patient Financial Clearance Matter?

In the complicated landscape of healthcare revenue generation, providers find themselves reliant on a delicate balance between patient payments and insurance reimbursements. On one front, the challenges emerge from the complexity of navigating coverage complexities and addressing potential leaks in claim payments from insurance entities. Simultaneously, providers grapple with the difficult task of engaging patients to enhance collections, particularly in terms of their out-of-pocket responsibilities. A misstep in patient financial clearance can turn a smooth, profitable journey into a chaotic, resource-draining stumble.

This intricate dance between insurers and patient's insurance coverage underscores the critical necessity of obtaining financial clearance at the outset of the healthcare service. This proactive step becomes a strategic move for healthcare providers seeking precise control over their revenue cycle. Here’s why:

  • Untangling the Insurance Puzzle: Clearance tackles the insurance puzzle head-on. By verifying coverage upfront, you identify missing authorizations, potential claim denials, and out-of-network surprises before they derail your revenue. Think of it as defusing financial time bombs before they even get near your bottom line.
  • Hidden Revenue Leaks: Incomplete or inaccurate information can lead to denied claims, delayed payments, and ultimately, lost revenue. Clearance acts as a financial radar, detecting potential issues before they become costly sinkholes.
  • Forecasting with Precision: Imagine steering a ship without a compass. Lack of clearance leaves you flying blind, unsure of patient responsibility, and unable to predict revenue inflow accurately. Clearance acts as your financial compass, providing precise data on expected payments and letting you chart a course for optimal reimbursement.
  • Patient Friction and Frustration: Facing unexpected bills or navigating complex financial processes can leave patients feeling frustrated and disengaged. Proactive clearance fosters transparency and builds trust, ensuring a smooth and positive patient experience.
  • Operational Roadblocks: Rushing to collect payments at the point of service is not only inefficient but can also clog up your administrative systems. Clearance allows you to proactively address financial concerns upfront, streamlining workflows and freeing up resources for better patient care.

True patient financial clearance goes beyond basic verification. It requires a holistic and proactive approach, incorporating strong financial advocacy to not only benefit your practice but also empower patients with knowledge and support throughout their healthcare journey.

How is Patient Financial Clearance Different from RCM?

Patient financial clearance isn't just another RCM checkbox; it's the foundation on which the entire revenue cycle stands. Patient financial clearance acts as a proactive gatekeeper, ensuring financial clarity before services are rendered, whereas revenue cycle management (RCM) is a broad set of activities like claim coding, submission, payment processing, and A/R follow-ups that drive revenue collection after services are provided.

Many healthcare providers opt for the expertise of medical billing companies or RCM service vendors to address specific tasks such as insurance verification or prior authorization within the overarching RCM framework. However, it becomes apparent that patient financial clearance stands out as a crucial step requiring dedicated consideration, separate from routine RCM activities. This separation is essential to fully realize its impact on the overall success of a medical practice. A robust clearance process not only simplifies and streamlines RCM but also addresses many revenue cycle issues originating from inadequate patient financial clearance.

Investing in patient financial clearance proves to be more cost-effective than resolving issues retroactively, as it prevents revenue leaks before they occur. By committing to robust clearance processes and leveraging advanced technologies, healthcare providers not only fix the front end but also improve cash flow to pave the way for a smoother, more profitable healthcare journey for all stakeholders involved. As described earlier in 'Key Practices that improve staff productivity in Sleep Centers', by understanding and automating these processes well, you can free up your staff's time and focus on the things that add real value to your business, such as patient care and revenue generation.

Modern Financial Clearance Platforms

We've established that patient financial clearance is the silent hero of the healthcare revenue cycle. However, navigating the complexities of insurance verification, authorization hurdles, and cost estimates can be a manual marathon for healthcare providers. Enter the patient financial clearance platform – your trusty AI-powered co-pilot on this financial journey. Data-driven technology is transforming patient financial clearance, unlocking a world of efficiency and transparency.

Patient financial clearance processes, crucial to the revenue cycle, have the biggest opportunity to be modernized - to apply software automation and for AI to bring efficiency. However, generic RCM software or medical billing service companies are not in the best position to leverage this opportunity since that’s not what they are designed for. Healthcare practices need a specialized solution in patient financial clearance specifically for this purpose. When we speak to practice owners on our podcast, The Efficient Care, we hear a resounding need for a tool that goes beyond basic insurance verification and claim coding. They express a need for a patient-centric platform that empowers clear communication, proactive cost estimates, and streamlined prior authorization, alleviating administrative burdens and boosting patient satisfaction."

So, what features should a patient financial clearance tool have? A patient financial clearance platform automates the heavy lifting, streamlining processes and freeing up valuable time for you and your staff. Here’s a list of things that you should look for in it:

  • Insurance verification: Does it verify eligibility and benefits in real-time across multiple payers?
  • Cost estimation: Can it generate accurate and transparent cost estimates based on patient insurance and planned procedures?
  • Prior authorization management: Does it streamline the prior authorization process with electronic prior authorization requests and automatic notifications?
  • Patient communication: Does it offer a clear explanation for patients to understand how their out-of-pocket payment responsibility is arrived at?
  • Integration: Does it seamlessly integrate with existing systems to avoid data silos and manual data entry?  

SmartVerify: Your Partner in Patient Financial Clearance Success

Aarogram is leading innovation in this space by applying AI and automation technologies. The patient financial clearance platform- SmartVerify built by Aarogram is a powerful tool that is specially designed to handle the critical activities of insurance verification, patient estimation, and prior authorization. Aarogram’s platform empowers healthcare practice staff with an AI-powered SmartVerify automation engine to speed up patient financial clearance processes. This translates to smoother patient experiences, reduced administrative burden, and improved financial performance for your practice. And no need to worry about setup! SmartVerify's seamless integration and our expert support team make transition a breeze, maximizing your ROI from day one.

Investing in patient financial clearance isn't just about collecting money – it's about building a solid foundation for success. Patient financial clearance is not just a box to tick; it's a paradigm shift.

In today's competitive healthcare landscape, a streamlined patient financial clearance process is no longer a luxury, it's a necessity. Aarogram's SmartVerify platform gives you the edge you need to stand out. Empower your staff, delight your patients, and maximize your revenue with the power of AI. Don't just survive, thrive with Aarogram.

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