Face denials if you don’t ID right `exchange’ plan
Executive Summary
Claims denials will result if patient access staff incorrectly identify the correct payer when patients present with coverage obtained on the Health Insurance Exchange Marketplace.
• Post sample cards on the hospital’s intranet for patient access employees to refer to.
• Make carrier phone numbers available to staff.
• Flag plans as "out of network" so patients can be informed upfront.
Patients risk large out-of-pocket costs
Patient access leaders at Wheaton Franciscan Healthcare in Glendale, WI, worked hard to educate staff on the new plans available on the Health Insurance Exchange Marketplace.
Carriers typically provide many different "exchange" plans, each with different levels of benefit offerings, explains patient access manager Terri Miles. "If the plan a patient participates in is not clearly identified upfront, it could result in a huge out-of-pocket for the patient," she says.
This situation could end up as bad debt if the patient doesn’t have the means for payment. "This ultimately affects the facility’s financial viability," says Miles. Reduced patient satisfaction is another concern. "Patients expect us to be the experts. They expect us to be able to provide this information to them," says Miles.
Patient access staff lose credibility with the patient if the patient’s out-of-pocket cost is higher than the original estimate because an incorrect plan was selected, she adds.
Tami Cheatham, patient access services representative III at OSF Healthcare in Peoria, IL, says, "As insurance cards are constantly changing, this makes it difficult to choose the appropriate plan codes." When contacting patients to pre-register them for scheduled services, OSF Healthcare’s registrars sometimes ask if there any identifying icons on the card. This question sometimes helps them pinpoint the correct plan.
Patient access managers at OSF Healthcare also display actual cards of new "exchange" plans so staff can easily identify those plans, says Cheatham. (See related stories, p. 80, on giving staff "visuals" to identify plans and identifying which plans are out of network, right.)
Selecting a plan code is one of the major steps that patient access staff members are responsible for, emphasizes Connie Longuet, MBA, MHA, CHAM, director of patient access services at The University of Texas M.D. Anderson Cancer Center in Houston. "If we don’t get it right, everything is wrong from that point forward," Longuet says. Problems include wrong claim routing, missed filing deadlines, and manual rework for the billing department. "Patients may be dissatisfied if their claims aren’t resolved correctly and quickly the first time," adds Longuet.
Denials are avoided
OSF Healthcare’s patient access managers did a focused audit recently specifically to identify incorrect plan codes.
Jessica Atkinson, project specialist in engineering administration, said, "We looked at every single account that came into our outpatient center in a certain timeframe. Just by doing that, we have caught a lot of errors."
Any incorrect plan code that was verified gets sent back to the employee who made the error, so that he or she can go back into the system to correct it, says Atkinson.
At Wheaton Franciscan, patient access managers made carrier phone numbers available to staff. "We verify eligibility and provide cost estimates to our patients upfront," explains Miles. "If a payer is not automated through our computerized eligibility tool, we do have to make verbal outreach."
During these calls, staff members verify that a patient is eligible for coverage and that the policy and/or group number is accurate.
"We review the benefits available for the service to be provided, so we can complete the patient estimate," says Miles.
