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Give patients a straight answer on out-of-pocket, or they may leave
Your patients might need to plan ahead
How much will I owe for this procedure?" Your response to this seemingly simple question from a patient could be the deciding factor as to whether he or she chooses your facility, says Marcy Quattrochi, manager of financial counseling at NorthShore University HealthSystem in Evanston, IL.
"Often times, they are shopping for the best price and may seek services elsewhere," Quattrochi says.
A patient's out-of-pocket responsibility isn't always easy to determine, but more patients are demanding this information upfront, according to Sandra N. Rivera, RN, BSN, CHAM, director of patient access at St. Joseph's Healthcare System in Paterson, NJ. "This allows for the patient to properly financially plan ahead, instead of receiving a bill later for an unknown amount," she says.
The price you quote can be the difference between a patient having a procedure at your hospital or somewhere else, says Rivera. "Some patients are starting to price shop," she adds. "They will even tell you the price they received from another facility."
Many patients are not aware of their deductible or out-of-pocket expenses, says Quattrochi, and they find it difficult to calculate what they will owe for any given service. A patient recently called for the price for a magnetic resonance imaging (MRI) test she was scheduled to have, she says. "Based on the patient payment estimator, we were able to inform her of an exact price for the test and what her out-of-pocket expenses would be," says Quattrochi. "At that same time, we were able to arrange a payment plan for her patient portion not covered by insurance."
If a patient is admitted to the hospital, the insurance verification department verifies his or her benefits, says Quattrochi, and the financial counseling department contacts the patient if there will be a large amount that is going to be owed.
Patients with scheduled services often call to find out how much they're going to owe, Quattrochi adds. "There are a lot of people who are very concerned because of higher deductibles," she says. "If they're unable to pay the portion not covered by insurance, we do have a very generous charity care policy."
Patient access staff and financial counselors use newly implemented price estimation software to estimate what patients will owe for scheduled services, she says. "It gives us their copay, their deductible, and their estimated amount owed," Quattrochi says. "We are able to access this in many areas of the hospital, so we can have a conversation with the patient regarding their benefits."
The system gives an estimate based on previous patients who have had the procedure with a specific doctor, explains Quattrochi, but cost still varies from patient to patient, depending on time in the OR and recovery room, and necessary supplies.
Medicare coverage is particularly difficult to explain to patients, notes Quattrochi. "It is based on how many days you are inpatient within a specific timeframe, and it gets very confusing to try to explain," she says. "If the patient is in-house and a family member wants to talk to somebody, we can go over it very specifically with them."
It's just an estimate
At Danbury (CT) Hospital, registrars are careful to give patients as close an estimate as possible, says Cindy Thomas, AS, CHAM, outpatient access manager. "But unless it is a clear co-pay, it would be just an estimate. You need to be extremely careful," she says.
It is difficult for staff to accurately estimate what portion of a deductible already is met and what to request as a deposit, Thomas explains. "It is safer to stay away from requesting co-insurance or even giving an estimate of what would be owed," she says. "There are too many variables."
For deductibles and co-insurance, says Thomas, a patient's balance will depend on how many physician visits, testing, or inpatient stays a patient has. "The balances are based on what bills hit first," she says. For this reason, staff members collect only copays. "This is a clear-cut expense," she says. "We can ask for this without the possibility of having to do a refund for overpayment."
Good estimates depend in large part on information from clinical areas, such as an accurate estimate of OR time and anesthesiology, adds Thomas. Patient access staff can't quote an exact price for an ED visit because this price is dependent on all of the testing that is done at the time of service, professional fees and level of care, she notes. "I have had ED patients from out of state request to pay cash upon discharge," says Thomas. "We do the best we can, but it is still difficult to come up with the exact fee."
Staff can give endoscopy patients a close estimate, says Thomas, but if they find polyps during the test there will be additional biopsies and pathology fees. For surgical patients, OR time can change during the procedure, she notes.
"Everything has variables. We tell the patient we can tell them only what we know for sure. The rest we will not know until after treatment and discharge," says Thomas. "Usually, this is accepted by the patient." (See related stories below on providing explanations when collecting and verifying benefits.)
For more information on estimating patient out-of-pocket responsibility, contact:
Marcy Quattrochi, Manager, Financial Counseling, NorthShore University HealthSystem, Evanston, IL. Phone: (847) 570-2078. Fax: (847) 733-5223. E-mail: mquattrochi@NorthShore.org.
Sandra N. Rivera, RN, BSN, CHAM, Director, Patient Access, St. Joseph's Healthcare System, Paterson, NJ. Phone: (973) 754-2206. E-mail: firstname.lastname@example.org.
Cindy Thomas, AS, CHAM, Outpatient Access Manager, Danbury (CT) Hospital. Phone: (203) 739-8204. Fax: (203) 739-1905. E-mail: email@example.com.