Extra steps needed for 'exchange' plans
Time-consuming calls to payers necessary
Some patients who obtained "exchange" plans on the Health Insurance Marketplace are presenting to registration areas, with no proof of having done so.
Executive Summary
Patient access departments are seeing patients who purchased "exchange" plans on the Health Insurance Marketplace presenting without proof of coverage.
- Staff must contact the payer to obtain the patient's ID number and eligibility information.
- Patients don't always realize their coverage isn't effective yet.
- Registrars need scripting to answer questions from patients regarding exchange plans.
"We are seeing some patients that do not have their insurance card because they haven't received it. It's hard to identify that they actually have the coverage," says Tracy Bonnell, director of revenue cycle at St. Anthony's Medical Center in St. Louis, MO.
In some cases, patients whose coverage became effective several weeks earlier still are waiting to receive an insurance card. "We were surprised that patients wouldn't have access to an insurance card more quickly," says Bonnell. "We then do additional research to obtain the benefit coverage."
Staff members typically verify coverage with a real-time eligibility system, used for about 80% of payers. "Our system allows us to apply the patient's coinsurance deductible amounts and give them an estimate based off the particular plan," she says. However, the exchange plans are not yet in the system, and information on the exchange plans typically is not available from payer websites.
This issue means staff members need to call the payer to attempt to obtain the patient's ID number and eligibility information. "We typically call the health exchange directly, which we struggle with because of the hold times," Bonnell says.
Patients aren't turned away
Patients on exchange plans are in some cases presenting for services believing they are insured, when their coverage has not yet become effective.
"In that situation, it's a challenge to verify coverage. We are not turning any of those members away," says Angad S. Buttar, MHA, senior manager of revenue cycle operations for Kaiser Permanente's Mid-Atlantic States Region in Rockville, MD.
Buttar advises patient access leaders to first ask registrars what questions they're hearing from patients regarding exchange plans, and then provide staff with scripting to answer those specific questions. "Being proactive is the only way to go here," Buttar says. "Someone may not have answered a question effectively. But the next time a patient comes in with the same question, we can be sure to knock it out of the park."
These are the two most common questions registrars have fielded:
- "I signed up online. Can you confirm my coverage?" For this request, registrars refer the patient to the member services department.
- "What amount do I owe, in addition to my premium?" "Once we receive the appropriate eligibility and coverage information, we will bill these members, if necessary, for any co-pays or other cost share they owe for the services provided," says Buttar. Registrars do not collect cost shares, deposits or co-pays from individuals who state they have coverage which is not currently showing up in the system, he explains.
Patient access employees aren't always able to answer a patient's question, sometimes because limited information is available about the exchange plan. "The first thing is for registrars to understand their own limitations," Buttar says. "If you don't know a policy's effective date, what information do you know that can help the person out?"
If the question can't be answered, says Buttar, "there may be an internal resource within the organization that could assist the patient," he says.
The registrar might be able to get the answer by calling the payer, or by putting the patient in touch with an insurance verification specialist. Similarly, patient access leaders can network with peers at nearby facilities to share information on exchange plans.
"Talk to other hospitals or physician groups in the region, and ask them about what they are seeing," Buttar advises. "Keep that communication open."
- For more information on patients presenting with exchange plans, contact:
- Tracy Bonnell, Director of Revenue Cycle, St. Anthony's Medical Center, St. Louis, MO. Email: [email protected].
- Angad S. Buttar, MHA, Senior Manager, Revenue Cycle Operations, Kaiser Permanente Mid-Atlantic States Region, Rockville, MD. Phone: (301) 816-6448. Fax: (301) 388-1743. Email: [email protected].
