Helping patients understand their insurance

Helping patients understand their insurance

Plans with $20,000 deductible in marketplace

Patient access employees probably believe that insurance companies have an obligation to fully inform consumers about the coverage they’re getting. Unfortunately, this belief doesn’t always translate into reality.

"It’s easy to say that the payer should be doing this, and most do try hard to explain. But as benefit plans get more complex, members don’t often fully understand their benefits," says Jen Nichols, senior director of revenue cycle operations at Kaleida Health in Buffalo, NY.

Nichols is seeing plans with an out-of-pocket maximum in the tens of thousands. "Unfortunately that is not uncommon these days. Where in the past a patient might have had a $2,000 maximum, now $20,000 plans are in the marketplace," she says. "Folks used to having a more robust benefit package are trying to adjust to this new reality."

Patient access employees at Ochsner Health Systems — Baton Rouge (LA) Region are seeing an influx of patients with plans ranging from major medical, limited medical, mini-medical, micro-medical, and medical discount. "These plans advertise themselves to the public as innovative,’ but really, some are only good for catastrophic purposes," says Elizabeth H. Broadway, CHAM, director of patient access and business services.

Patient access staff must step up to fill the role of informing patients about their coverage, argues Nichols.

"For the last several years, having a really robust pre-arrival department was considered a best practice," says Nichols. This best practice means that patient access intervenes just prior to scheduled services or sometimes when patients are shopping for quotes.

This step is still important to do very well, she says, but Kaleida’s patient access employees are taking it a step further. "There is a role for us to play in helping patients to understand their benefits even before the patient has presented on the pathway to services," says Nichols.

Financial counselors, called "navigators," now provide outreach in the community to assist patients in enrolling in Medicaid and exchange plans, even prior to needing healthcare services. Nichols says the outreach makes it less likely patients will present for catastrophic — and costly — events, since they’ll presumably be getting better preventive care. "This will help patients to be healthier ahead of time, so they hopefully don’t need us for a costly, catastrophic illness that may put both their personal finances, as well as hospital revenue, at risk," she says. If patients do present for a catastrophic illness, they will have the security of having some level of coverage to assist them.

Previously, patient access were stuck in a "reactive" mode, says Nichols. Staff waited for a patient to contact them or waited for a physician to refer them, before helping them to obtain coverage or understand their existing coverage. "We now have an opportunity to be proactive, to help patients enroll even before they need us. So when they do need us, they are well-covered," says Nichols. "That takes the anxiety off the patient. It is one less thing to worry about."

If patients present for services without insurance, the financial navigators still help them to apply and enroll in traditional Medicaid or any of the nine plans available through the state’s exchange.

"We are not an insurance broker and we make no profit on this," Nichols explains. "We are trying to help patients sign up early for coverage and connect them with the right coverage plan."

Earlier is better

Whether patients are presenting for services, or do not need coverage yet, patient access employees take the approach "the earlier in the process, the better," says Nichols.

Employees use an internally developed application to provide accurate, timely quotes to patients. "Resolving finances early on reduces stress on the patient. It also clearly reduces our cost to collect," says Nichols.

If no one educates patients on their coverage, it causes problems for the patient and the hospital, due to a longer time to collect, increased bad debt, and less reimbursement, says Nichols.

"Then there is the goodwill factor," says Nichols. "It’s hard to quantify that. But if we are upfront with patients, they might not like what we tell them, but they believe we are a committed partner with them."

At Mercy Hospital in Springfield, MO, some patients consider cancelling surgery due to high out-of-pocket amounts. "We offer a low-interest bank loan and payment arrangements to enable them to go ahead with surgery," says Rebecca Holman, CHAM, patient access manager.