Patients might owe more at your facility
Benefits may differ according to site
Even if a payer considers your hospital to be "in network," it might cost a patient more to obtain a service at your facility due to varying tiers of benefits for various facilities.
"This is a new twist that people may not be aware of," says Brad Davenport, director of the patient access center at The University of Tennessee Medical Center in Knoxville. "The patient may be in network but may have reduced benefits if they come to our facility."
Even though it's the payer's requirement, patient access staff are the ones who have to explain it to the patient standing in front of them, says Davenport. "We feel like it's our responsibility to make patients aware of it," he says. "Very few patients realize this. It's much worse for them to find it out on the back end."
Staff members tell the patient the additional amount they'll owe if they have the service at the facility and let them make the decision. "Some patients may say, 'I'm so glad you told me that,' or they may say, 'I'm coming there anyway,'" he says. "It depends on how badly they want to go to the facility."
Confusion results
Davenport says that his staff members often are in the position of telling patients that Medicare might not cover the services, because Medicare might determine the service is not medically necessary or a covered procedure.
"We are dealing with that pretty regularly," he says. "We try to resolve it beforehand. But if the patient is here, all we can tell the patient is that it may or may not be covered."
This situation is confusing to patients because they don't understand why a service their physician thinks they need to have might not be covered, he adds.
Staff members work hard to educate patients about their coverage and plan requirements, Davenport says. "We tell them all hospitals are under these same regulations and we are providing the information so they can make an informed decision," he says.
Staff tell patients, "It appears this service may not be covered by Medicare, as it may not meet their medical necessity requirements. You can still have this service, and we will bill Medicare. But if they do not cover this, you may be responsible for the charge."
Timing is key
"More tests are requiring certification. The sooner we can determine whether we have financial clearance, the more time we have to resolve the issues," says Davenport.
"Timing is everything" to avoid problems with services being denied, he says. A provider initially might order an magnetic resonance imaging scan, but the payer might require that an X-ray or CT scan be performed instead. "They may deny an inpatient admission and require a service to start as outpatient," he adds.
Staff members make every attempt to resolve these coverage issues before the scheduled date of service. "If we determine this ahead of time, the patient can decide if they are still going to have the service," Davenport says. "Or they can contact their physician about the plan of care."
Source
For more information on educating patients on their coverage, contact:
Brad Davenport, Director, Patient Access Center, The University of Tennessee Medical Center, Knoxville. Phone: (865) 305-9018. Email: [email protected].
Even if a payer considers your hospital to be "in network," it might cost a patient more to obtain a service at your facility due to varying tiers of benefits for various facilities.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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