Knowing benefits just first step to reimbursement
Providers must follow payer's guidelines
With a lot of new insurance packages, it's not enough just to know what the benefits are. Patients and providers must follow an insurer's guidelines exactly for benefits to be paid.
"It is increasingly difficult for the consumer to navigate the system. What we are trying to do is to inform them of any information we have so they can make good decisions," says Kate Brennan, RN, BSN, director of admitting and case management for the Rehabilitation Institute of Chicago (RIC).
RIC's outpatient access department staff have been trained to educate the public on how to determine what their benefits package contains and how to make decisions about treatment based on what will be covered. For instance, a package might cover home health but not outpatient treatment. Patients need to know ahead of time and decide which option is best for them.
"Our staff would tell patients that outpatient service isn't within their benefit package and suggest that they call their insurer and see if they could get treatment under another provision of their benefit package," Brennan says.
Before the new system was implemented, RIC often was in the position of treating a patient without assurance it would be paid.
"It was a lose-lose sort of situation. When a patient came in, and we determined their insurance wouldn't cover it, we had the option of turning the patient down, which is not our preferred approach, or taking a hit financially," says Chris Frommelt, RN, BSN, MBA, the project specialist who worked on the re-engineering team that created the new system.
Staff discuss benefits with patients, what's covered and what isn't, and what the patient's responsibility will be to pay for treatment that isn't covered. Now, before patients come into RIC for treatment, the hospital knows it will be paid, and patients know their policy will cover the treatment.
"One of our big focuses is creating the right situation on the front end to make an appropriate billable account on the back end," Frommelt adds.
Under managed care, it's not enough to know what is required for billing. You have to know what information you need to be reimbursed, she points out. "With the new system, we've gotten to the point where we are assured that we have more complete information than before."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content