You must get ready now for many more eligibles
‘Great increase’ in volume expected
Patient access departments need to prepare for a “great increase” in the volume of patients who are eligible not only for Medicaid, but also private insurance policies, as a result of the Patient Protection and Affordable Care Act (PPACA) according to Luis Guerrero, director of patient access services at Ochsner Baptist Medical Center in New Orleans.
“This will require more attention to detail and collection of data in order to process the bill properly,” he says. “One part that will become critical is providing the patient with clear information about their benefits and responsibilities.”
Presumptive eligibility determination requires a high level of accuracy, adds Guerrero. “It won’t be enough to ask the patient, ‘How much did you make last week?’ or ‘Can you provide us with your last eight paystubs?’” he says. “We will have to critically analyze the different components of eligibility.”
This step is necessary to reduce errors when directing patients toward the right type of coverage and to reduce reimbursement delays arising from the patient having to refile when presumptive eligibility has been incorrectly determined, says Guerrero.
“In addition to that, the price estimation and patient responsibility estimation will need to be carefully presented on two fronts: under the presumptive eligibility, and under the self-pay standards,” he says. “We will be required to provide information that is clear and concise.”
More data to collect
Ochsner Baptist recently created a preservice center to improve patient flow and prevent delays. “We have already started to put actions in place, so that come 2014 we will be fully prepared to take on all the additional cases that will go through that center,” Guerrero explains.
The pre-service area is designed to perform a comprehensive access process for patients. During the pre-service phase, the team validates patient information and insurance data, obtains authorizations, details benefits, and calculates patient responsibilities. “If financial counseling is needed, our pre-service center facilitates the access so patients don’t have to take additional time from their busy days,” he adds.
Guerrero expects to see increased wait times in the emergency department and for same-day walk-in services as a result of the PPACA, due in part to the increased amount of data staff will need to collect. “We will have to be sure to collect any shred of data regarding the individual policies that will allow us to create clean claims,” he says. “For the insured patients, we will not have to collect ‘new’ data — instead, the volume of cases where we will have to create a payer in the system may increase dramatically.”
For patients who are not insured, data collection might include demographic data to adequately determine presumptive eligibility, he adds.
Flexibility is needed
“Because of Epic and other tools, we won’t have to stay on the phone an hour waiting for an authorization or verification. Most of that is done electronically now,” says Guerrero. “It’s still going to be a challenge at the very beginning when we go from having 600 payers to 6,000 payers, but with the right tools, we will minimize the impact.”
Jack Smarr, MHA, associate director of revenue management for UK HealthCare in Lexington, KY, says that financial counselors within his patient access department are used to working with self-pay patients, and an external vendor is used to process applications for Medicaid and disability.
“This model has worked well for us in the past. But with the shift away from self-pay, we may be able to make that an internal function again,” says Smarr. “If the volume of ‘newly eligible’ spikes, we have the flexibility with our vendor to accommodate that increase.”
Patient access departments need to prepare for a great increase in the volume of patients who are eligible not only for Medicaid, but also private insurance policies, as a result of the Patient Protection and Affordable Care Act (PPACA) according to Luis Guerrero, director of patient access services at Ochsner Baptist Medical Center in New Orleans.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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