`Skinny’ network plans growing — Patients blindsided by changes
Patient access faces lost revenue and unhappy patients
Executive Summary
Patients are increasingly presenting with out-of-network coverage, due to more "narrow" networks in health plans. Patient access needs revamped processes to confirm eligibility, inform patients, and apply for patient-specific agreements.
- Internal and payer-specific tools can determine if patients are in network.
- Some departments have added staff to educate patients on the need to apply for exception requests.
- Patients are typically unaware of their out-of-network status due to similar-sounding names of health plans.
In 2013, many patient families in the Seattle area purchased an insurance plan from a large payer that included Seattle Children’s Hospital. A few months later, the payer transitioned the families to a "narrow" network that no longer included the hospital.
"The payer did this without changing the name of the plans, and, according to our families, without enough communication to explain the change," says Suzanne Vanderwerff, senior director of revenue cycle value stream at Seattle Children’s.
As a result, patient access staff are seeing many patient families trying to schedule appointments with doctors that their children have seen many times before — often, since birth — but their doctors are no longer in network. "We have to explain to the families that they will now have to pay out-of-network rates to be seen at our hospital," says Vanderwerff.
More health plans are looking to "skinny down" their networks, reports Michael Lawton, vice president of managed care and network development at UF Health Shands Hospital in Gainesville. "As an academic health system, we have a unique cost structure that does not allow us to compete in the same way a community hospital does," he says. "So we are often left out of these skinny’ networks."
At Emory University Hospital in Atlanta, patient access employees have had problems with several locally available plans purchased on the Health Insurance Marketplace, which are out-of-network for Emory hospitals. "Patients get really upset to discover their plan excludes us," says Pete Kraus, CHAM, CPAR, FHAM, business analyst for revenue cycle management. "We’ve collaborated with our insurance verification vendor to catch these during pre-admit."
Emory’s patient access leaders also have asked carriers to provide better education to their plan holders. "The situation is complicated by the fact that the plans will pay for emergency or transplant-related services," says Kraus. "These are difficult to catch upfront in our largely automated system."
Eligibility software used by patient access employees at Cottage Hospital in Woodsville, NH, gives immediate information on the patient’s benefits, but doesn’t indicate whether the hospital is in-network.
For outpatient clinics and therapy services, patient access employees call the patient’s insurance carrier prior to the initial visit and verify in-network status. "This way, we can inform the patient upfront of where their services stand," says Jennifer White, director of patient access.
The state’s exchange plan selected a very limited number of facilities and providers as in-network. "Everyone else is out-of-network," says White. "This has been a challenge. Patients do not understand their plans, and facilities and providers have limited understanding."
Staff have to tell patients that the hospital is not in-network with their plan and that services will be out-of-pocket. "Patients are not happy. They feel it is our fault, but we were not given an option," says White. "It is a challenging conversation to have."
Better verification processes
Before 2014, there was no need for patient access leaders to put significant emphasis on determining whether patients are enrolled in "narrow" network plans. "But that has changed," says Vanderwerff.
Patient access employees at UF Health Shands use various systems to determine and confirm patients’ network eligibility. "Through our admission process, whether through our physicians’ access area or the hospital admitting area, we have UF Health System tools and payer-specific tools that we use," says Lawton.
Many insurance products have similar names, patient familiarity with their insurance is low, and insurance cards don’t always reflect the most updated information. "There is neither an easy nor an efficient process to identify if a patient is out-of-network," says Vanderwerff.
At Seattle Children’s, patient access staff members search payer website portals to confirm what insurance product the patient has, or they call the health plan if the portal doesn’t provide this information. "Many of the products sold by the insurance plans have very similar names," adds Vanderwerff. For this reason, patients usually are unaware of their out-of-network status.
"A patient may think he or she is purchasing a product that includes the same physicians and facilities as the previous plan," says Lawton. "Later, they find out that this is not the case."
Patients sometimes find that the services they need are not available in the network or are only available by traveling significant distances. In these cases, out-of-network hospitals can sometimes work with the plans to secure patient-specific agreements. "These agreements, while occasionally successful, often lead to delays in care, frustration for the patients and family, frustration for the physicians, and potential harm to the patient," says Lawton.
Seattle Children’s Hospital offers many pediatric specialty services that patients can’t get anywhere else in the region.
"We spend a great deal of time filing exception requests on behalf of patients, so that families can pay the in-network rates," says Vanderwerff.
Scheduling for patients with "narrow" network coverage that doesn’t include Seattle Children’s takes significantly longer than usual. "This is because the patient families need us to explain the extra steps that they, and we, must take before we are able to schedule an appointment," says Vanderwerff.
In some cases, staff members file "exception requests" with the payer so the patient can continue to be seen at the hospital. However, this filing is possible only if there is no in-network provider in the area who can provide the pediatric specialty services the patient is seeking.
At Seattle Children’s, dedicated, knowledgeable staff were added to handle a large number of exception requests to narrow network payers on behalf of out-of-network patients. "They spend much of their time educating patients on the need to file an exception request," says Vanderwerff. "Most people outside of the healthcare industry do not understand the plans or the coverage."
• Pete Kraus, CHAM, CPAR, FHAM, Business Analyst in Revenue Cycle Management, Emory University Hospital in Atlanta. Phone: (404) 712-4399. Fax: (404) 712-1316. Email: [email protected].
• Jennifer White, Director, Patient Access, Cottage Hospital, Woodsville, NH. Phone: (603) 747-9252. Fax: (603) 747-9342. Email: [email protected].
