Don't wait too long — Verify patient's coverage

Outpatient surgery POS collections jump 47%

Patients gradually are becoming accustomed to being asked for payment upfront, according to Marcy Quattrochi, manager of financial counseling at NorthShore University HealthSystem in Evanston, IL.

"If you go into a doctor's office nowadays, you are expected to pay your copay," Quattrochi says. "Patients are pleased to know what they're going to owe. They may need to budget or make payment arrangements for a procedure. I think it is very, very positive."

At the same time financial counselors inform surgical patients about their estimated out-of-pocket expense, they ask for a deposit or payment upfront. "Right now, we are doing this for select services only, but patients seem to be very pleased with it," Quattrochi says. "Our point-of-service collection has definitely increased."

Point-of-service (POS) collections for fiscal year 2011 increased by 46.9% for outpatient surgery compared with the previous year, she reports.

"The major change we made is that we are verifying benefits further out, instead of a day or two before," Quattrochi says. "We prefer not to call a patient right before he or she is coming in for surgery." If the insurance is verified a week out, says Quattrochi, it gives staff enough time to have a conversation with the patient before their scheduled services.

Patients might be registered as self-pay because registrars don't have the insurance information before they come into the hospital, says Quattrochi. "The registration areas work with the doctor's offices to obtain that information before they come in, if they do have insurance," she says.

In some cases, says Quattrochi, patients are genuinely surprised to find that they qualify for financial assistance. "Our charity program is very generous," she says. "Many people have the misunderstanding that only those unemployed or with little income can qualify. You can have a substantial income and still qualify for a discount."

Well-informed patients

For elective cases, registrars at St. Joseph's Healthcare System in Paterson, NJ, verify benefits, verify that an authorization has been obtained, and determine the patient's out-of-pocket responsibility, says Sandra N. Rivera, RN, BSN, CHAM, director of patient access.

In the past, registrars only collected copays because calculating the co-insurance and deductible was so complex, says Rivera. "We are now working on being able to calculate the co-insurance and deductible as an estimate prior to elective services," she says. "This is a new process for us. It is being rolled out in stages."

Registrars use price estimation software that takes into account payer contracts, the patient's benefits, and 18 months of billing history, says Rivera." To be able to provide an accurate estimate, you need all this information," she says.

Registrars contact the payer to learn how much the patient has paid toward the deductible and what the balance is, says Rivera. "The more information you can share, and the more transparent the process, the better informed the patient is," she says. (For information on estimating out-of-pocket expenses, see story, below.)

Sources

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: riveras@sjhmc.org.
  • Cindy Thomas, AS, CHAM, Outpatient Access Manager, Danbury (CT) Hospital. Phone: (203) 739-8204. Fax: (203) 739-1905. E-mail: cindy.thomas@danhosp.org.

Give straight answer on out-of-pocket expenses

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.

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 for a large part on information from clinical areas, such as an accurate estimate of OR time, 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.

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 story on providing explanations when collecting, in box below.)


Asking for payment? First, give explanation

When a patient asks what he or she will owe for a procedure, registrars at St. Joseph's Healthcare System in Paterson, NJ, consider the payer contract, procedure code, procedure amount, and patient benefits, says Sandra N. Rivera, RN, BSN, CHAM, director of patient access.

"Registrars must be able to properly explain the health insurance benefits to the patient, including covered benefits, authorization requirements, and in- and out-of-network coverage," she says.

Most payers have a web site and customer service phone number for patients to call with any questions, notes Rivera, but patients prefer receiving a written estimate. Previously, registrars collected only on the day of service, says Rivera, but collections have moved to the pre-registration process. "This allows patients to go directly to point of service when they arrive," she explains.

Staff use scripting to practice asking for payment, and they often use the words, "Would you like to pay by cash, check, or credit card?"

"They also need to understand how we come up with the estimates," she says. "They need to answer any questions the patient may have."

Registrars soon will be able to hand patients a brochure with information on the payment process, financial assistance programs, and where to go for assistance, says Rivera. Physicians, patient financial services, planning and development, the hospital's chief financial officer, patient access, and the marketing department are working together to create the brochure, says Rivera. "The brochure can be given to patients at any time in the process," she says. "We also created a patient access video that is played in our lobby. It explains the registration process to patients as they wait."

At times, staff members connect the patient directly to the insurance company via telephone to discuss their coverage, says Rivera. "This allows for the patient to speak directly to the payer and have the information explained firsthand," she says.

If the patient still is confused about their benefits, says Rivera, the case is referred to a manager. "This allows management to review any issues with the staff that may need clarification," she says. "It also helps to identify any payer trends or process changes that may need to be addressed."