7.1 Patient Access & Charge Capture
Key Takeaways
- Patient access (registration, eligibility, and authorization) prevents the majority of avoidable claim denials before a claim is ever built.
- The HIPAA 270 transaction requests eligibility and benefit information; the 271 transaction returns the payer's response, confirming coverage, deductible, and copay.
- The Master Patient Index (MPI) is the database that uniquely identifies each patient and prevents duplicate or merged records that corrupt billing.
- The Medicare Secondary Payer (MSP) questionnaire must be completed at registration to determine whether Medicare pays primary or secondary.
- Charge capture is the process of recording every billable service from the encounter form, superbill, or EHR so no revenue is lost.
Why Patient Access Matters
Quick Answer: Patient access is the registration and verification stage of the revenue cycle. Industry studies attribute roughly half of all claim denials to front-end errors — wrong demographics, expired coverage, or missing authorization. Fixing these issues at registration is far cheaper than appealing a denial later.
The revenue cycle begins before a patient is even seen. Patient access (sometimes called front-end registration) collects the data every downstream billing step depends on. A single transposed policy number or an outdated insurance plan can turn into a denied claim, a delayed payment, and an unhappy patient.
Registration Data
At registration the biller or front-desk staff must capture:
- Demographics — legal name, date of birth, sex, address, and contact information that must exactly match the payer's records.
- Guarantor — the person financially responsible for the account (often the patient, but a parent for a minor).
- Insurance details — payer name, plan, member ID, group number, and the relationship of the patient to the subscriber.
The Master Patient Index (MPI) is the facility's authoritative list of every patient and their unique medical record number. A clean MPI prevents duplicate records (the same patient entered twice) and overlays (two patients merged into one record) — both of which scramble billing and clinical data.
Eligibility Verification: 270/271
Electronic eligibility verification uses two paired HIPAA transactions:
| Transaction | Direction | Purpose |
|---|---|---|
| 270 | Provider → Payer | Requests eligibility and benefit information |
| 271 | Payer → Provider | Returns coverage status, deductible, copay, and limits |
Verifying eligibility confirms the policy is active on the date of service, identifies cost-sharing amounts, and reveals whether services need authorization.
Prior Authorization
Prior authorization (precertification) is the payer's advance approval for a planned service. Without it, an otherwise covered service is denied. Billers track the authorization number, the approved CPT/HCPCS codes, the number of approved visits or units, and the valid date range — and report that number on the claim.
Insurance Card Review & Point-of-Service Collection
Reviewing the insurance card (front and back) confirms the payer ID, the claims mailing address or payer ID for electronic submission, and customer-service phone numbers. Collecting the copay at time of service (TOS) improves cash flow and reduces the cost of billing the patient later. Financial counseling helps uninsured or high-balance patients understand estimates, set up payment plans, or apply for charity care.
Medicare Secondary Payer (MSP) Questionnaire
Medicare is not always the primary payer. The MSP questionnaire, completed at registration, screens for situations — active employment with group health coverage, work-related injury, auto/liability accident, end-stage renal disease, or veteran benefits — where another payer must pay first. Billing Medicare primary when it should be secondary is an overpayment and a compliance risk.
Charge Capture
Charge capture records every billable service performed during an encounter. Charges flow from the encounter form / superbill (a checklist of common codes) or directly from the EHR charge module into the practice management system. Missed or lost charges are permanently unbilled revenue, so reconciling the schedule against captured charges is a daily best practice.
A provider's office submits an electronic eligibility request to a payer before a patient's visit. Which HIPAA transaction does the office send?
At registration, a Medicare patient reports she is 67, still working, and covered by her employer's group health plan with 25 employees. Based on the MSP questionnaire, who is the primary payer?