Will healthcare reform mean more or less revenue for access?
March 1, 2012 4 minutes read
Will healthcare reform mean more or less revenue for access?
Coverage changes already occurring
Will changes in patient coverage due to the Patient Protection and Affordable Care Act (PPACA) mean less revenue for your organization, more opportunities for patient access, or both?
Although some aspects of healthcare reform still are being challenged in the courts, "no matter what avenue it takes, the impact to patient access cannot be underestimated," says Gail Draper, director of clinic support services at University of Utah Hospitals & Clinics in Salt Lake City. "We need to be successful at issues relating to service, technology, and cost-shifting for the new regulations that are already here, with more fast approaching."
Already, the patient access department at University of California Los Angeles Health System is seeing decreased reimbursement because many ED patients formerly covered by fee-for-service Medicaid plans are switching to managed care Medicaid plans, says Bernadette Lodge-Lemon, director of revenue cycle. "With subsidized care, our reimbursement is compromised," she says. "We only receive a small per diem, which doesn't cover our costs."
Many more patients will have coverage when the PPACA is fully implemented in 2014, says Lodge-Lemon, so their out-of-pocket expenses will be less. "But I believe it will negatively impact our collection rate," she adds. "Many healthy young people will enroll in the state-sponsored plans, which means less reimbursement for providers."
Because the hospital is not contracted with the Medicaid HMOs, the patients are difficult to manage, financially and medically, says Helen Contreraz, director of patient access services. Patients covered by Medicaid HMOs are not bound by the same rules as patients with federal Medicaid plans, Contreraz explains, and they can change their coverage every month. "Because the programs are fairly new, the fiscal intermediary has had a lot of system challenges," she adds. "They have different medical groups that manage them. A multitude of areas are processing their claims."
Because of this issue, "it takes a lot more time on the front end to financially secure the patient. You have to really dig deep and delve into all the details," says Contreraz.
At least one phone call typically has to be made during business hours, or the third party administrator (TPA) might need to be contacted during off-hours. "Anytime there is a TPA or division of financial responsibility, it takes more follow up and training of staff," adds Contreraz.
The patient's primary care physician might not be familiar with the patient. "Many times, they defer to the HMO," she says. "By the time the call is made on the first business day, the patient may have already been discharged."
Lodge-Lemon says she expects the trend toward Medicaid HMOs to continue, with many more patients insured by state-sponsored plans in 2014. To maintain revenue in light of this, UCLA's patient access areas have made these changes:
Services are shifted to the appropriate facilities.
"We have made changes in where we are treating patients," says Lodge-Lemon. "We are doing some internal strategic handling of patient care, all being followed by the same set of physicians."
Increased bed capacity and geriatric and orthopedic services were added at the organization's Santa Monica UCLA Medical Center, and the number of intensive care unit (ICU) beds was increased at Ronald Reagan UCLA Medical Center, so patients not requiring ICU-level care are shifted to Santa Monica. "We have centralized insurance verification and preadmission," adds Lodge-Lemon. "That means that even though staff physically sit at Ronald Reagan, they are also working the Santa Monica cases."
Additional case managers were added in the emergency department (ED).
About 40% of hospital admissions come through the ED, all of which are unscheduled. "That is another point where we can assess the patient and determine if they are better situated at the Santa Monica facility or whether we should keep them at Ronald Reagan," says Lodge-Lemon. "Of course, the patient has to agree to go to Santa Monica if they enter through the ED at Ronald Reagan."
Staff work hard to provide the right information to the medicine department.
"We conducted a lot of training, developed scripts, monitored by shift, and updated our registration screens," says Contreraz. "We send out a day-end report to the coordinator for the service."
The service coordinators want to know, for example, whether the patient has a primary care physician in the UCLA network, because that will determine who is going to be seeing the patient. "They are our largest service, so we have to be aware of what their needs are," says Contreraz. "We nee d to capture the right information that is going to help them with their patients."
Job descriptions of registrars were updated to reflect new skills, including financially securing cases.
"We are investing resources into our internal staff instead of looking externally," says Lodge-Lemon, adding that job descriptions will be updated again later this year after the department implements a new hospital information system.
Staff members are expected to know which medical groups the hospital is contracted with, says Contreraz. "Otherwise, the claim may be forced through, but we don't have a payer agreement," she says. "Those claims may prove problematic, so it's really important that the staff understand who the contracted groups are."
Sources
For more information on the changes underway in patient access due to health care reform, contact:
Helen Contreraz, Director, Patient Access Services, University of California Los Angeles Medical Center. Phone: (310) 267-8005. E-mail: [email protected].
Gail Draper, Director, Clinic Support Services, Community Clinics, University of Utah Hospitals & Clinics, Salt Lake City. Phone: (801) 213-9555. Fax: (801) 213-4761. E-mail: [email protected].
Bernadette Lodge-Lemon, Director of Revenue Cycle, University of California Los Angeles Health System. Phone: (310) 794-8299. E-mail: [email protected].
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