Staff-designed calculator gives instant copay totals
OTC collections increase
A "Patient Responsibility Calculator" (PRC) dreamed up by an admitting supervisor and brought to fruition by an employee in the reimbursement department enables staff at Sonora (CA) Regional Medical Center to quickly calculate copay amounts and let patients know how much they owe before the service is performed.
Over-the-counter (OTC) collections from patients at the time of service increased dramatically with the use of the PRC, says
Julie Betts, admitting supervisor at Sonora Regional, including an additional $30,000 to $40,000 a month for diagnostic imaging and another $30,000 a month for scheduled surgeries.
In early 2003, as a new supervisor, she wanted to be able to give patients — even those who were unscheduled — the correct copay amount so they could make more informed decisions, Betts explains.
"I wanted something [that would] pull information from our managed care contracts and from our chargemaster by CPT code," she continues. "It could be a set rate or a percentage of payment — everybody has a different [method]."
Fortunately, Betts was joined in her quest by Sean Watkins, who worked with the hospital’s information systems manager to devise the PRC, she explains. "Without their buy-in, [the idea] would have just sat there."
Because of fee schedule changes, the PRC has to be updated yearly and now is maintained by two other employees in the reimbursement department, Betts notes. The PRC is accessed by an icon on a computer desktop and primarily used by financial counselors and preadmission staff.
"First we have to know what [service] the patient is having and verify the benefits," she adds. "Then we open up the PRC. How we use it depends on the type of service and the [insurance] carrier."
If the patient is fee for service, "we input the insurance information, and it tells us how much the patient will owe," Betts says.
"If the patient is going to have a $5,000 MRI, and insurance pays at a certain amount, but we have a contract rate for them, we select the insurance, the CPT code, and then it prints out [the copay amount]," she continues.
Although Betts had the hospital’s large outpatient population in mind when she envisioned the tool, it also works for inpatients, she adds.
"Inpatient [amounts] are the easier ones," Betts says, noting that having the PRC enables staff to come up with a figure more quickly, rather than calculating percentages for more expensive services in their heads.
"If the patient asks, How much will I have to pay?’ we can tell them without having to pull up files somewhere," she notes. Before the PRC, access personnel had to go into the insurance text, read it, find the description of benefits, and then look in another computer program to find the payment for that fee schedule.
"It just makes [collecting copays] so much easier and so much more user-friendly," Betts says.
"Our accuracy level is pretty good. We tell the patient that if [clinicians] change the service, that changes the price. Patients are much more knowledgeable. They know what they are responsible for, and they can pay that or a portion of it," she explains. "If it’s too expensive, they can ask the physician if there’s another test that can be done instead."
While patients typically are informed of their financial obligation just prior to the service, "they could call a month in advance if they’re shopping around and let us know that they have Blue Cross, for example, and these are their benefits," Betts adds.
[Editor’s note: Julie Betts can be reached at 209) 536-3480.]
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