Managers seek relief from new HMO headaches
Managers seek relief from new HMO headaches
Identifying the right plan poses challenge
Just when access managers thought Medicare and Medicaid regulations couldn’t get any more troublesome, they were faced with a new twist — working with the Medicare or Medicaid patient in a managed care plan.
As more and more seniors select Medicare HMOs and states seek to increase Medicaid managed care as a cost-saving measure, registrars face several potential headaches at the point of service.
Although MeritCare Health System in Fargo, ND, doesn’t deal with managed care for its own state’s Medicare and Medicaid beneficiaries, it gets its share from a neighboring state, says Karen Duffy, MS, manager of patient services. "We are a border city, and we get lots of Minnesota Medicaid patients. They’re almost all in a managed care plan, and the problem is determining exactly which plan."
Most patients aren’t used to having regular health insurance and are unfamiliar with the practice of showing a card when they receive health care services, she notes. In some cases, patients don’t even know what plan they chose. "We end up doing education for the state of Minnesota."
If the registrar is able to identify the managed care plan but discovers that the patient is out of network, there’s a new challenge, she points out. "Those patients are required to sign a form saying they’re responsible for paying the bill themselves. But if they’re on medical assistance, they probably don’t have the money to pay. We know that even if they sign it, you can’t get blood out of a turnip."
The registrar is faced with tactfully suggesting that the patient wait to get a referral or seek care at an in-plan facility, Duffy says. "If we choose to see these patients, it’s free care. We can’t bill them unless they sign, but what is the agreement worth if they don’t have money?"
At Burdin Riehl Ambulatory Care Center, part of Lafayette (LA) General Medical Center (LGMC), the challenge also lies in identifying the Medicaid or Medicare patient as a true HMO member, says Jeri Pack, admissions/diagnostics manager.
"Another kicker is that they can move in and out of that HMO on a monthly basis," she notes. "You almost have to verify their coverage on every visit, so it’s very time-intensive."
In fact, a state requirement — effective in July 1998 — that Medicaid eligibility must be checked on every visit prompted some technology solutions that are helping her staff get a handle on the problem. "Starting last summer, no longer did [Medicaid beneficiaries] have a paper verification card issued monthly by family," she explains. "Each individual was issued a plastic ID card that is good indefinitely, but we have to check eligibility on every visit."
Because it wasn’t feasible for registrars to stay on the phone, checking eligibility for every patient at the point of service, the decision was made to purchase Medifax on-line verification software from the Potomac Group in Nashville, TN, Pack says. "The software is being interfaced with our HBOC patient registration system by our information management technology systems department." HBOC software is manufactured by HBO and Company in Atlanta.
Automatic inquiries made
Once the system is operational, Pack says, there will be a pop-up screen on every registrar’s computer on which the patient’s social security number or name and birth date can be entered. As the registration proceeds, the Medifax system will make an automatic electronic inquiry to the appropriate fiscal intermediary or payer.
"The information [on eligibility] will come back and populate the screen," Pack says. "[The registrar] doesn’t have to leave the computer, doesn’t have to place a call, doesn’t have to leave the registration."
There’s some time-consuming preparation required, however, before the automated system will be functional, she says. In addition to the interface with the HBOC system, preparation includes installation of a value-added network (VAN) line and construction of a firewall to protect the VAN line. To handle the Medicaid requirement in the interim, LGMC purchased some Medifax point-of-service verification machines.
Using those machines, which are placed in key registration areas, registrars swipe the patient’s card and get a printout that verifies Medicaid coverage, Pack says. Just recently, it became possible to access the Medicare intermediary through this system, as well as three commercial payers.
Because of the time it takes to swipe the card and get the printout, and because she can afford to have the machines only in major locations, Pack says she is hopeful the on-line system will be up and running by late spring or early summer of 1999. Negotiations are under way to bring other payers, besides Medicare and Medicaid, into the on-line system.
"Ultimately, my goal is to have as many payers as possible able to be verified by this method," she says. "It’s the most productive and most accurate and most timely system."
(Editor’s note: Next month’s issue of Hospital Access Management will explore the comprehensive continuous quality improvement program, focusing on access services, developed by LGMC.)
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