Staff should work for patients, not insurers
Teach employees when to stop explaining benefits
Train your intake staff to be "top-notch Dick Tracys," scrutinizing every patient that comes through the door to make sure they have a complete picture of that person's insurance coverage. Has anything changed with the patient's health plan? Is she really on traditional Medicare, as her card indicates, or has she switched to a Medicare HMO, with its accompanying restrictions?
That's the advice health care financial consultant Karen Hurley, CMM, CPC, CPAM, gives hospital access managers. In addition, she suggests teaching employees when to stop explaining insurance benefits. Explanations should come from the insurance or managed care company, says Hurley, who owns Hurley Practice Manage ment Services in the Washington, DC, area. Hospitals and physicians don't get paid enough to take on educating patients about insurance coverage, which they don't provide, she says.
Insurance company customer service representatives need to be available to the patients, in essence their customers. If the physician's office staff tell a patient, "This service isn't covered by your plan," and the patient responds with, "What do you mean, they don't cover it?" don't try to explain, she advises. "Let the patient speak with the health plan directly, right in front of you."
Hurley suggests providing the patient with a telephone, a pen, and a place to sit and make the call. In fact, when she designs space for health care facilities, she puts the billing office "right around the corner" from the registration area, and includes a place there where patients can call their insurance provider for clarification.
When a patient angrily says, "You have to accept this out-of-plan referral, simply answer, "No, we are not required to do so" and allow the patient to use the phone to contact the carrier, she says. "The patient is paying the insurance company, so let the company do the work." She recommends the billing staffer sit with the patient until the situation is resolved.
Insurance companies generally have one number for the health care provider to call and another for the patient, and the patient's is always toll-free, she points out. "One of the best tools you can offer is the telephone."
Hurley says she frequently performs "crisis management" for physicians' practices, responding to situations that begin with, "My office manager ran out screaming, 'No more!'" When she meets with the front-office staff to redesign systems, she often finds that they are "explaining [health plans] to patients out of the book." An employee is conditioned to be as helpful as possible to the patient and will say something like, "Do me a favor. Just bring your book [insurance manual] in, and I'll explain it to you."
"We get out of that mode immediately," she says. "It's not [the provider's] responsibility to explain benefits to patients."
She tells staff in health care billing officers who are "pulling their hair out, trying to get paid," not to engage in repeated calls to the insurance company's customer service line. Instead, she asks who the insurance company's representative or liaison with that provider is and advises the billing office to bring that person onto the scene.
"Show them the problems with the claims and have them solve the problem," Hurley suggests. "The representatives are paid to work for the providing facility. Make them help you."
When an insurance company or health plan refuses to allow for a physician's services in full, such as not recognizing certain services that may have been preauthorized, she advises the patient to take the claim to the state insurance commissioner's office. If the health care facility involved is participating with that health plan, "contact the representative for the plan and have them work with you to resolve the issue," she says.
Hurley suggests the health care provider give the patient a letter to accompany the denied claim or services. The letter should explain that the provider follows the federal coding guidelines for billing, and the health plan in question has decided certain services are not appropriate according to those guidelines.
The bottom line: She's lost patience with the reactive approach to health care reimbursement. "I don't allow my clients to work for the insurance companies. I have them work for the patients."
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