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Benefits advisor develops rapport with payers
Getting proper authorization for insurance benefits during the referral stage can deflect bad debt and increase client satisfaction. One home health agency in Denver, which handles both Medicare and commercial accounts, has created a position health benefits advisor (HBA) just to verify benefits and develop a rapport with the insurance companies.
"The HBAs have built strong relationships with our payers," says John Kettler, systems analyst for Centura Home Health in Denver. "They know each other well."
Lynn Goodman, an HBA with Centura, verifies benefits for about 200 patients a week. Centura Health System is the result of a merger between St. Anthony’s Hospital system and Portercare Hospitals. Goodman verifies benefits for the home care coordinators at all the St. Anthony Hospitals and Portercare hospitals, as well as the benefits for Centura Home Health patients.
A large percent of Centura business has been on the Medicare side, but the commercial side is growing, says Kettler. "We do mostly high-tech services on the private duty side."
How the HBA operates
When a patient referral comes into the intake department, the department forwards the information to the HBA.
Using an insurance benefit certification authorization sheet that guides her, Goodman contacts the insurance company and verifies the benefits and effective dates of care. In most cases, she gets authorization for one visit. The patient is then given to Centura’s case managers to get authorization for the rest of the visits. The agency has separate case managers for capitated accounts and fee-for-service accounts.
Most of the insurance companies only cover skilled care mainly care provided by physical therapists, occupational therapists, speech therapists, or RNs, Goodman says. "Ninety-nine percent of commercial companies do not cover home health aides." (For more information on insurance coverage, see p. 118.)
If Centura doesn’t have a contract with a certain insurance company, Goodman often finds herself in the position of negotiating rates.
"They’ll say, Can you negotiate rates?’ and I’ll say, Yes, I can.’ Then they’ll ask our retail price."
Goodman has the license to go down a certain percentage from the retail price, but unless the company names a figure, she’ll negotiate the retail price down bit by bit. "They might tell me, This is what our contracts pay. Can you meet that price?’ And usually I do unless it’s really low. Then I say, No, I need permission for that.’"
Here are some of the advantages of creating an HBA position, says Goodman and Kettler:
• You reduce bad debt.
"We rarely have to rebill a second insurance company because of incorrect insurance information," says Kettler. "The HBA not only limits headaches; [the position] also pays for itself many times over by reducing bad debt."
• You have a designated contact person for the companies to call.
Centura didn’t have a contract with a certain insurance company, Goodman says. But after negotiating prices with the company and establishing a relationship, the company decided to use Centura. "They know they can call me if they have a question or complaint. They like our services, so they feel comfortable using us and they know who to go to."
• Your HBA becomes familiar with the requirements of the insurance companies.
HBAs begin to learn what they can and can’t do with each insurance company and when they have to give an absolute "no" because the rates are just too low, she says.
• The position lessens the burden on other staff.
"Our nurses are so busy they don’t have the time to develop a rapport with the insurance companies. And the hospital home care coordinators don’t either."
To aid communication with insurance companies, Goodman has created a database with information about each company she has contacted. This information includes the agency’s phone number, address, what benefits the company offers in general, and the name of the contact person.
"The database has helped, especially with obscure commercial insurance companies," she says. "I was given five different phone numbers for one company. It will save a lot of time now to know who to call there in the future."
Goodman also makes sure she documents every piece of information she receives. "Our home care software system has a page where we can write notes. On this page, I write whatever I’m finding on the insurance side for each patient."
For example, the notes might explain what benefits were authorized or why benefits were denied, as well as whom Goodman spoke to at the company. The information has helped accounts receivable personnel when they’ve had billing questions, she says.
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