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Discovering Missed Health Insurance Coverage: The 3 Most Common Types

Insurance coverage can be missed for many reasons, including incomplete or inaccurate patient demographic information, an unverified primary payer, resource constraints and more. Despite these reasons, it’s important to identify it early to get fully reimbursed for care rendered.

Many revenue recovery efforts can be done successfully through in-house processes. However, for obtaining hard-to-find coverage, an experienced external partner can help your team identify missed opportunities you didn’t even know existed which can make a big impact on your bottom line.

The most common sources of missed coverage come from the following accounts:

1. Self-pay

A patient who presents without insurance or doesn’t disclose any potential insurance coverage at the point-of-service is considered self-pay. This type of account typically drives the most uncompensated care for a hospital and is the best place to start to look for missed coverage. And for good reason as up to 60% of hidden coverage comes from self-pay accounts.

2. Medicaid secondary

Due to Medicaid Expansion and the ACA, it is now more common for patients to have more than one insurance provider. In cases where a patient has Medicaid and another insurance (commercial or Medicare), Medicaid will always be the secondary payer. Even as a secondary payer, Medicaid can represent valuable fee-for-service and cost report revenue.

Specifically, Medicaid secondary can:

  • Generate additional dual-eligible bad debt opportunities (paying $.65 per $1.00 of the patient balance)
  • Pay co-Insurance and deductibles for QMB
  • Drive additional DSH days to the cost report

3. Coordination of benefits opportunities

Coordination of benefits is needed when patients have more than one insurance plan. As mentioned above, the ACA created more scenarios where patients have both Medicaid and either Medicare or commercial insurance. In order for the claim to be properly paid, the correct primary and secondary payer need to be identified. Not identifying the appropriate primary payer can be costly, especially as timely filing deadlines come into play. For this reason, potential coordination of benefits opportunities need to be found as early as possible.

Commercial plans represent the greatest reimbursement potential, as 50–60% of the billed revenue (“sticker price”) for care is covered by a commercial plan, compared to 10% covered by Medicaid.

Learn more about how TransUnion Healthcare’s insurance discovery solutions can help you identify hard-to-find coverage and maximize your organization’s recoveries.

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