Executive Summary
Patient access faces difficult conversations with patients if services are non-covered. Taking the following steps can help stop lost revenue.
- Verify coverage for any services the patient will be having.
- Present options in a patient-focused manner.
- Explain what services are not covered, and why the Advance Beneficiary Notice of Non-Coverage must be signed.
Increasingly, patients are finding themselves responsible for the cost of non-covered services. This happens if the payer denies an authorization, or if Medicare doesn’t consider a test to be medically necessary.
“We then explore if the patient can make payment via payment plan guidelines we have in place,” says Jason Guardado, manager of patient access at Nyack Hospital in New York.
If not, financial clearance specialists determine if the patient meets the criteria for charity care assistance using the hospital’s eligibility screening process.
There is no scripting involved in any of these discussions. “Complex conversations such as these require seasoned staff with experience discussing financial assistance with patients,” says Guardado.
Financial clearance specialists have strong customer service backgrounds. “This allows them to present options in a patient-focused manner,” says Guardado. “The sensitivity of the patient’s financial anxiety is always in mind.”
Challenging Discussions
Patient access can stop patients from ending up with surprise bills for non-covered services with a simple step. “Verify coverage for any and all known services the patient will be having,” advises Peggy Stavitz, chief patient accounting officer at Brewer-based Eastern Maine Healthcare Systems.
However, this involves quite a bit of groundwork, some of which can be time-consuming. Patient access might need to call the payer, search payer websites, and use eligibility systems.
“Having done all the due diligence in advance of the conversation with the patient keeps the conversation on track,” says Stavitz. Patients can make an informed decision as to whether to have the services or not.
Equally important is obtaining an Advance Beneficiary Notice of Non-Coverage (ABN). “Without the ABN on file, patients cannot be held responsible for payment, in most cases,” notes Stavitz.
Stavitz finds that simple, clear scripting works best. The patient access employee should explain what services are non-covered, and why the ABN must be signed.
“Many times, this is a shock to the patient,” says Stavitz. “Having empathy while remaining professional is important.”
The same is true when patient access has to ask for payment in advance for the non-covered service. “These conversations can be difficult,” says Stavitz. “But the patient has the right to know and understand what their insurance will and will not cover.”
Involve Patient From Start
Verifying insurance to check whether services are covered is fairly straightforward. However, this typically happens only once — before patients receive services. “Many organizations fall short in following up during and after the services have been performed,” says Stavitz.
Patient access departments need both staffing and technology resources to verify coverage at regular intervals. If changes occur, it often means the claim gets denied. “Unfortunately, this is becoming more common. Patients are shopping around in an attempt to find coverage they can afford,” says Stavitz.
Patients opt for cheaper policies without realizing that the care they’re actively receiving is no longer going to be covered. In this case, says Stavitz, “The sooner the discussion takes place, the better the outcome.”
If services are non-covered, patient access must work with clinicians and care management to rectify the situation. The patient also should be involved from the very start.
“The conversation regarding signing an ABN and requesting payment for non-covered services should take place immediately,” says Stavitz.
- Jason Guardado, Manager, Patient Access, Nyack Hospital (NY). Phone: (845) 348-2316. Email: [email protected].
- Peggy Stavitz, Chief Patient Accounting Officer, Eastern Maine Healthcare Systems, Brewer, ME. Phone: (207) 973-4642. Email: [email protected].
