Out-of-network plans must be identified
Patient access informs patients upfront
Wheaton Franciscan Healthcare in Glendale, WI, is participating in only two of the plans available on the Health Insurance Exchange Marketplace.
This participation in two plans means that patient access employees must explain to some patients that the hospital is not "in network" with their plan.
"This has increased the amount of communication we are needing to do with our patients, whether they are new to our organization or have come to us previously," says patient access manager Terri Miles.
The new "exchange" plans were added to the Wheaton Franciscan’s computer insurance dictionary. "These reflect out of network’ when we do not participate in that carrier network," says Miles. "A simple OON’ was added to the end of the carrier name."
When "OON" is seen, anyone in patient access, whether a scheduler, registrar, or financial counselor, informs the patient that they are out of network. They explain that if the patient chooses to have services at Wheaton Franciscan, they will have a higher out-of-pocket cost. "As we are not always sure of what the insurance will pay — an out-of-network benefit level or no payment at all — we provide the patient with estimated charges for the total service," says Miles. "We make no promises around payment or discounts."
Staff members tell patients, "We have identified that Wheaton Franciscan Healthcare is not an in-network provider for your services. While you can receive your services here, you need to be aware you will have a higher out-of-pocket responsibility than if you were to use an in-network provider. To verify in-network providers, you will want to follow up with your insurance agent or carrier directly."
Registrars at The University of Texas M.D. Anderson Cancer Center in Houston document whether the patient’s plan is in or out of network on the benefits screen. "We provide patients with a written insurance summary that has the benefit levels listed on it," says Connie Longuet, MBA, MHA, CHAM, director of patient access services. The hospital is contracted with several "exchange" plans.
"At first, it was slow confirming eligibility," says Longuet. "Some payers were backed up on loading benefits, but it is pretty much back to normal times now."
Patient access leaders are at Wheaton Franciscan are reaching out to insurance plans for special consideration of extending in-network coverage for those patients who were in a course of treatment at Wheaton prior to choosing their new plan, reports Miles. Patients often are unaware of the limitations that "exchange" plans impose on where they obtain care, she says, especially those who are newly insured.
"We all know healthcare is a complicated business," says Miles. "We now have a lot of people selecting healthcare plans for maybe the first time."
