Electronic systems verify coverage on the spot
Electronic systems verify coverage on the spot
Denied claims, days in AR reduced
A patient hands you an insurance card with multiple numbers, numbers that are next to impossible to locate, or no numbers at all. Another patient neglects to mention that his or her insurance status has changed due to a job loss. Either way, insurance verification in real time could prevent a denied claim for the patient standing in front of you.
"With the current economy, we see a larger number of patients with no insurance or patients who have gone under an assistance program," says Kerri Sternhagen, patient business services trainer at Affinity Health System in Appleton, WI.
"All hospitals are seeing a substantial increase in patients whose insurance has changed since the last time patients were seen," says Cheri S. Kane, MSA, FHFMA, CHFP, FACMPE, division president of The Outsource Group in St. Louis and former vice president of revenue cycle at Grady Memorial Hospital in Atlanta. "In one Georgia hospital, self-pay patients recently increased from 5% to 18% due to employer layoffs in the local area."
For inpatients and high-dollar claims, Kane says that you might want to ask patients the questions: Have you recently been employed?" "Do you have access to COBRA?"
"If so, hospitals today are evaluating if it is cost effective to pay the patient's backdated payments so they can receive COBRA and subsequently file insurance," says Kane.
John E. Kivimaki, director of patient accounts at Mary Rutan Hospital in Bellefontaine, OH, says that his department has seen a large increase in the number of patients whose insurance status has changed over the past couple of years.
"The condition of the nation's economy, where jobs have been drastically cut and health care benefits slashed, has generated this change," says Kivimaki. "We have clear evidence of this large increase here in our area. The accounts we have written off to our charity and financial assistance programs have increased approximately 70% from October 2008 to October of this year."
Many of these patients are qualifying for assistance programs either because they no longer have jobs or because they have seen their health insurance coverage reduced tremendously. "This creates increased patient liabilities they cannot pay," says Kivimaki.
This scenario is uncomfortable for both the patient and yourself. "It is sometimes awkward when a patient comes in and their eligibility shows inactive," says Sternhagen. "If this occurs, the patient access staff will verify the policy and group number from the insurance card and try running the transaction again."
If the insurance eligibility still comes back as inactive, the patient is informed of this, and asked whether he or she has recently changed insurance or employment status. "If the patient says nothing has changed and they are still employed, we will keep the insurance listed as we don't want to alarm the patient. Sometimes slight changes in a patient's plan can appear to be inactive temporarily. We will ask the patient to contact their insurance company to check eligibility," says Sternhagen.
Sometimes, though, the patient just hasn't told access staff the truth - that they no longer have any coverage. "There will be times when the patient does not tell us their insurance plan is inactive. After verifying the information and it is determined the patient has no coverage, we will list them as private pay," says Sternhagen. The patient is given contact information for the hospital's business office, in order to get assistance with his or her financial situation.
To avoid a situation like this, though, private-pay patients are typically contacted before their appointment and assisted with any programs they may qualify for.
At Mary Rutan, all self-pay patients are given information on how to apply for assistance. "We also have charity/financial assistance in our statements. Our 'early out' vendors also are letting patients know of the assistance available to them," says Kivimaki.
"Many patients are failing to inform hospitals that they are self-pay," says Kane. "Patients are fearful that they will not be treated, or that they will be pressured to pay amounts that they don't have the funds to pay."
Recently, Affinity Health System implemented an online eligibility tool. This simplifies registration by obtaining patient information in real time from participating payers.
"Insurance eligibility, policy and group numbers are returned back from contracted payers, showing any discrepancies we may have from what the payer has on file," says Sternhagen. "A higher volume of claims are sent to the insurance company 'right the first time.'"
At the time of registration, staff already know if the patient is active or inactive. "This gives us an opportunity to ask more questions from our patients, to ensure they are giving us the most accurate insurance information," says Sternhagen. "Our days in accounts receivable for September 2008 were 40.18. In September 2009, they were at 35.25. We're excited to see the decline in the outstanding days in A/R."
The patient access department at Mary Rutan Hospital has seen similar success since it implemented electronic eligibility in 2004 to verify insurance information. Initially, a batch process was utilized, where files of daily registrations were accessed by the vendor and then sent to payers for eligibility verification.
For the last year, however, the department has used a patient dashboard to do a real-time verification of eligibility at the time the patient is being registered. "We still have the batch process running to give us valuable information on copays and deductibles that is sometimes unavailable from the dashboard," says Kivimaki.
This eligibility process gives up-to-date insurance information on policy numbers, policy holders, copays, and deductibles, depending on the payer. "Any information that the patient gives us at the time of registration or pre-registration is verified with the payer immediately," says Kivimaki. "We receive the payer's response in less than 30 seconds."
If the payer response comes back ineligible, staff can then tell the patient that he or she has no coverage with that plan. "A lot of times, the employer has changed their insurance and has not distributed the insurance cards to their employees," says Kivimaki.
The same eligibility process is used to verify insurance coverage if patients have called in to report a change in coverage. The patient may not know his or her specific payer information or policy number, so this is obtained by staff directly from the payer's response. "We then have all the necessary information to bill the account correctly," says Kivimaki. "This has prevented a number of claim denials in this area."
$1.2 million is uncovered
Mary Rutan uses the same eligibility process to identify Medicaid managed care plans of Medicaid patients and Medicare Advantage patients and their specific plans and co-pays.
Registered self-pay accounts are run against the state's Medicaid eligibility files to determine if the patient has Medicaid coverage at the time of registration. As a result of this practice, $1.2 million in Medicaid billable accounts was uncovered in 2008. "We have uncovered many accounts where Medicaid applications were pending or just recently approved," says Kivimaki. "We also created two other files that are run against payer eligibility files. These have brought a substantial amount of money to our hospital."
First, a pending bad debt file is run once a week, which consists of accounts ready to be charged off as a final check before they go to bad debt. "The other file we have created is a bad debt file. This consists of all bad debt accounts with dates of service within one year of the date the report is run," says Kivimaki. "This is done since our state has a one-year billing time limit for Medicaid-eligible accounts."
[For more information, contact:
- Cheri S. Kane, MSA, FHFMA, CHFP, FACMPE, Division President, The Outsource Group, 3 City Place Drive, Suite 690, St. Louis, MO 63141. Phone: (937) 367-6590. E-mail: [email protected].
- John E. Kivimaki, Director, Patient Accounts, Mary Rutan Hospital, 205 Palmer Avenue, Bellefontaine, OH 43311. Phone: (937) 592-4015, Ext. 5616. Fax: (937) 599-2143. E-mail: [email protected].
- Kerri Sternhagen, Patient Business Services Trainer, Affinity Health System, 222 W College Avenue, Ste. 4B Appleton, WI 54911. Phone: (920) 628-9028. Fax: (920) 628-9019. E-mail: [email protected].]
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