Is the patient’s insurance active? A simple “yes” or “no” once was all patient access had to know.
“Plans used to be more straightforward. Now, we need to do investigative digging,” says Andrew Ray, director of the professional revenue cycle at Stanford (CA) Children’s Health.
About 30% of the department’s claims denials have a root cause of incomplete or inaccurate registration.
“An increasing percentage of those [nearly 40%] are due to not accurately capturing the granular plan details,” Ray adds. “This requires significant rework by our follow-up staff to resolve.”
Here are four problems patient access faces:
- More complex plans take a toll on productivity.
“A straightforward registration process takes five to seven minutes,” Ray says. “But the added plan complexity can easily double that.”
This means delays at registration and sometimes in care scheduling.
“The sad result is that it’s added another layer to get through,” Ray notes. “The process becomes longer when we want to provide a quick process for patients.”
Registrars make many more time-consuming calls to payers to discover the details of what’s covered.
“We are having a lot more ‘one-off’ situations, working with payers,” Ray says.
It takes up to 30 minutes to get the needed information. Sometimes, registrars learn that there is hardly any coverage at all, since the hospital is out of network.
“The out-of-network benefits are often close to not having insurance, because the deductibles are so high,” Ray says.
Most patients usually have no idea that their plan has changed, or that a certain service or provider isn’t covered any longer.
“It’s a tough conversation to have with folks, especially when they have existing relationships with our physicians,” Ray laments.
The department has had success in getting plans to make an exception for specialty care and patients in midstream care with an ongoing health condition. In some cases, they’ve been able to prove the hospital employs specialists to handle what the patient needs, while in-network providers don’t.
“We have less success at getting considerations around general routine sick care,” Ray reports.
- Big balances surprise patients.
“This can result in patient bills of hundreds to tens of thousands of dollars, depending on the clinical complexity of the services,” Ray says.
Registrars field some very complex questions about out-of-pocket costs. Frequently, patients express frustration and even anger.
“Quite often, folks are upset with us. I understand where they’re coming from,” Ray says. “In every other business transaction, the financial pieces are fairly well known.”
Patient access is in a difficult spot.
“We are trying to sort out what’s going on with a particular patient. Where they are in their deductible and coinsurance cycle is sometimes unclear,” Ray notes.
Patient access could overstate the potential liability — it’s possible that more of the deductible or coinsurance was met than is apparent — or just wait until everything processes.
“Then we have a potential surprise, which is not good service,” Ray explains. “The solutions we’re left with are not great, across the board.”
Without better education when patients buy insurance, sometimes the best outcome is to “at least limit the surprise a little bit,” Ray says.
The more accurate and complete the insurance information is, the more accurate the out-of-pocket estimate is.
“We make patients aware of financial assistance and payment plan options. They can weigh that versus seeking care elsewhere,” Ray adds.
- Cards look almost exactly alike, and plan names are almost the same, but offer very different coverage.
“Getting down to the extra granularity of detail with the plans we’re dealing with is new over the last couple years,” Ray explains.
Registrars might register the patient as presenting with an in-network plan, failing to realize that it’s a slightly different plan — one that’s out of network with the hospital.
“None of our [systems] trigger us to alert the patient that they are out of network and will have a high out of pocket [expense],” Ray says.
- The number of insurance plans has surged.
Health plans create a multitude of different networks and products.
“For us, a lot of it is just trying to stay on top of that. It feels like a lot of times we’re playing catch up,” Ray says.
Stanford Children’s patient access department handles about 450 different plans.
“Most of our major payers have added at least one to three new plans,” Ray explains. “With many payers, the number of plans has doubled.”
Technology Flags Glitches
Patient access is adapting with revamped insurance verification processes, technology, and training.
“We are coming at it from multiple angles,” Ray says.
Plans aren’t always what they appear to be. The sooner patient access realizes it, the better. One frustrating obstacle is that the electronic eligibility data obtained from health plans often are vague and misleading. Ray explains, “Many times the detail is just too high level.”
It’s unrealistic to expect registrars to notice every slight discrepancy in hundreds of plans. Instead, the registration system flags potential problems, such as a member ID or group number, indicating the hospital isn’t in network.
“Within our systems, we’re trying to find ways to flag folks that this is one of the scenarios where we have a different relationship than we used to,” Ray says.
It doesn’t help that patients rarely carry their insurance cards — they expect those to be on file. Tinnie C. Garlington, BSB/PJ, CHAM, manager of financial counseling and quality assurance at Emory Healthcare in Atlanta, says, “Therefore, when their coverage changes, there is a challenge when attempting to identify what type of plan the patient has.”
To address this, the hospital created an insurance verification master committee.
“We work together to identify and solve insurance verification challenges,” Garlington explains.
Recently, the committee tweaked the hospital’s registration system so it notifies users if a plan is non-participating.
“This allows us to have the conversation with the patient regarding how they would like to proceed with their visit,” Garlington notes.
Registrars notify someone on the committee about any plan changes once someone becomes aware of such changes.
“Updates to the system are then made to reduce the issues with patients not being financially cleared prior to arrival,” Garlington says.
Small differences in plan names have been the cause of many claims denials. For instance, the patient may still have Humana coverage, where previously the patient presented with a Humana National POS plan. And although the two plans sound similar, the new plan actually is an HMO.
“We have to be very cautious, because the plan name may change unknowingly to us,” Garlington explains.
At Stephens Memorial Hospital in Norway, ME, if a scheduled procedure isn’t covered by the patient’s insurance, the registration system alerts registrars, who then discuss the situation so the patient can make an informed decision about what to do.
Kelly C. Moore, manager of Stephens’ central registration, says, “The patient has a right to get the services and bill their insurance, knowing it might not be covered, have the test and not bill their insurance, or not get the test at all.”
Very soon, this will happen earlier in the process.
“In the near future, the provider practices will be dealing with the advanced beneficiary notice during the patient encounter,” Moore says. “It will be dealt with at that time either by the provider or by front-end staff.”
- Tinnie C. Garlington, BSB/PJ, CHAM, Manager, Financial Counseling & Quality Assurance, Emory Healthcare, Atlanta. Phone: (404) 251-3910. Fax: (404)251-3761. Email: [email protected].
- Kelly C. Moore, Manager, Central Registration, Stephens Memorial Hospital, Norway, ME. Phone: (207) 744-6042. Fax: (207) 743-1598. Email: [email protected].
- Andrew Ray, Director, Professional Revenue Cycle, Stanford (CA) Children’s Health. Phone: (650) 723-9810. Email: [email protected].
Much revenue is at stake, if registrars misinterpret the patient’s coverage.
“Surgical and inpatient services are often $25,000 and up. Given the specialty nature of our care, it is not uncommon for services to cost six and seven figures,” says Andrew Ray.
Registrars at Stephens Memorial Hospital in Norway, ME, were entering insurance information incorrectly into the Epic system.
“My staff were not ‘billers,’ prior to our new computer system,” explains Kelly C. Moore.
Quality assurance staff discovered the problem during quality assurance audits.
“We review what was manually entered into the patient’s chart versus the image of the scanned insurance card, which is kept in the patient’s medical record online,” Moore says.
According to Moore, there were three problems:
- Registrars chose the incorrect insurance plan.
- Registrars typed in the incorrect insurance number.
- Registrars failed to scan the card into the patient’s medical record.
“Re-billing was needed, stalling payment to the hospital,” Moore says. “This crossed over to the patient, who wondered why it wasn’t done correctly in the first place.”
Registrars now consult tools provided by payers, such as examples of insurance cards for different plans.
“These tools are very helpful. We also do rounding with staff as new insurances are uncovered,” Moore adds.
Registrars are required to check their email prior to starting their shift to keep updated on plan changes. For instance, registrars used to document an observation patient’s status only for Medicare.
“Now we are doing this for all payers, to let the patient know they are an outpatient,” Moore notes.
Often, patients don’t understand this when they are in a hospital bed.
“If this document isn’t signed, we could lose revenue for over-the-counter prescriptions,” Moore adds.
Patients and Providers Need Training on Plans, Too
Many have no idea of coverage limitations
Patients don’t understand their coverage. Providers schedule services without realizing the patient’s plan doesn’t cover the provider, the service, or the hospital. Patient access staff are the only ones standing between this scenario and a denied claim, lost revenue, and an unexpected bill for the patient.
“We are coming at it from both angles,” says Stanford Children’s Health Andrew Ray. Here is how patient access departments are educating all involved parties.
Most patients have no idea of the specifics of what their plan covers. They don’t even realize they could be out of network. Emory’s Tinnie C. Garlington, BSB/PJ, CHAM, says, “Most patients view having coverage as if they are able to see any provider in any situation.”
Patients are surprised to learn that certain procedures are not covered, or that procedures were denied due to untimely notification.
“Our goal is to avoid costly denials,” Garlington says.
Stanford’s registrars are expected to answer questions from patients about what a service will cost them, regardless of the plan.
“We still struggle with this, but we are getting better at it,” Ray says, noting that in some cases the patient is the one who has to contact the health plan. “Patients don’t necessarily have the expertise to initiate the request. We’re doing a lot of education on that piece.”
Patient access ask patients to do these two things:
- Research their insurance before scheduling, especially what the plan covers for that particular service, and whether the hospital is in network.
- Provide specific details so it’s clear exactly which plan the patient has, instead of just a basic plan name such as “Aetna PPO.”
- Providers
Clinicians are consulted more often to resolve thorny coverage issues.
“We see this quite often,” Ray notes. “We’ve seen a big shift in the last year, with clinicians being much more involved than ever before.”
This usually happens after a patient gets a big bill because of a high deductible or going out of network.
“Oftentimes, it is the providers who patients feel most comfortable with in venting this frustration,” Ray notes.
Providers have advocated successfully for patients in this scenario by calling or writing the payer.
“In some cases, they have gotten the insurance to cover the services in network,” Ray says.
This is true particularly for specialty and sub-specialty services, whereby the patient may not have any other options in the area. Other times, though, there’s no wiggle room no matter who calls the payer.
“We are basically informed that we’re not considered in network. We are not given a whole lot of choice,” Ray says.
Providers aren’t experts in insurance — nor do they want to be.
“They just want to treat their patients. To have an administration issue limiting or delaying care is quite frustrating,” Ray says.
“There are so many changes, and we have relationships with hundreds of payers and health plans,” Ray explains. “The industry is evolving so quickly.”
Keeping all patient access employees updated is a daunting challenge.
“We have hundreds of registration staff at 65 sites, and another 100 or so at providers’ offices. To get all the information out to everyone is a challenge in itself,” Ray says.
Emory Healthcare’s schedulers as well as its pre-registration and pre-certification teams all receive continuous updates on plan changes.
“Everyone should be knowledgeable on how to communicate the patient’s benefits,” Garlington advises.
