Executive Summary
Patient access is taking on the role of rescheduling procedures if authorizations are missing, Medicaid coverage is pending, or the hospital is out of network. At Presence Health, $79,000 in revenue was prevented from being written off at one site in a single month, by rescheduling when necessary. To avoid postponing scheduled procedures, do the following:
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Ask whether the hospital is in network when verifying the patient’s insurance.
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Inform providers’ offices if a required authorization is not in place.
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Educate providers’ offices on payer requirements and patient access processes.
A patient is scheduled for an MRI in three days, but the payer says it could take five business days to obtain the required authorization.
“Therefore, the patient must be rescheduled,” says Amanda Hayes, regional director of patient access at Presence Saint Joseph Medical Center in Joliet, IL, and Presence St. Mary’s Hospital in Kankakee, IL.
By rescheduling surgical procedures or high-dollar diagnostic tests when necessary, $79,000 in revenue was prevented from being written off at one of Presence Health’s sites in a single month.
At Birmingham, AL-based Baptist Health System, patients often are unhappy initially to learn their procedures are being rescheduled. “But it’s an even bigger dissatisfier for the patient to have a procedure that’s not going to be paid for,” says Janice Ridling, vice president of revenue management. “For us, it’s a matter of doing the right thing for everybody involved.”
When procedures need to be postponed at Presence Health, a scheduler tells the patient, “Your insurance company requires this authorization to be in place to ensure they will pay for your services.”
“Most patients are ultimately very happy when they hear this,” says Hayes. “They do not want to be responsible for full payment of the services.”
No auth in place
A common reason for postponing a procedure is that the ordering physician office was not aware of the need for authorization.
“In some cases, the precert has gone to peer-to-peer review, and the payer is requiring extra time,” notes Ridling. Here are some other reasons why patient access might need to reschedule a patient’s procedure:
• The patient’s coverage is out-of-network.
“With some of the new plans, the patients aren’t being notified of this in advance,” says Ridling. “This is especially upsetting if patients have come to our facility for years.”
While verifying benefits, pre-registration staff members now ask specifically whether the hospital is in network. “We advise the patient if they’re out-of-network. If the patient has out-of-network benefits, we quote those,” says Ridling.
Pre-registration staff members also contact the physicians’ offices to inform them of the patients’ out-of-network status. “At that point, it becomes the patient’s decision whether they want to continue as planned or coordinate with their doctor to have the procedure done elsewhere,” says Ridling.
• A patient is expected to qualify for Medicaid, but coverage is pending.
In such cases, rescheduling of elective procedures benefits the patient, the hospital, and the provider’s office, says Linaka Kain, manager of the Marketplace Exchange and a disability examiner at Unity Point Health System — Rock Island (IL).
“We verify with the doctor if it’s something that is medically urgent or if it can wait,” says Kain. “We do that a lot more now. It makes it easier for everyone, and the patients appreciate it.”
Patients often consider only the cost of surgery, and they often forget about follow-up care and prescriptions. “Patients may think they will have the surgery and be done, but what about after that? Some offices won’t see uninsured patients,” notes Kain.
Patient access staff members tell patients, “If we can hold it off until you get insurance, you will have a far better outcome,” and they are careful to use the word “reschedule” instead of “cancel.”
“Everybody is going to have at least one prescription after surgery,” says Kain. “What if it’s a $300 medication, there is no generic available, and the patient has no money or insurance to pay for it?”
Rescheduling until coverage is obtained means the patient won’t receive a bill he or she likely can’t afford. “The doctor wants to get paid as well,” notes Kain. Patient access recently took on the role of determining the patient’s financial status. “It’s pretty difficult for the physician to do that on their side. We decided we’d extend the olive branch and take the extra step of doing it,” says Kain. “It’s been beneficial to all of us.”
• Some patients are unwilling or unable to pay their out-of-pocket responsibility.
The average deductible for employer-sponsored plans increased to $1,217, up from $826 in 2009, according to a September 2014 survey conducted by the Kaiser Family Foundation and the Health Research & Educational Trust.
Registrars increasingly are taking on the role of rescheduling non-urgent services for patients who are unwilling or unable to pay their out-of-pocket responsibility upfront, according to Paul Shorrosh, CHAM, founder and CEO of AccuReg Front-End Revenue Cycle Solutions in Mobile, AL.
“As hospitals continue to shift to a ‘payment-before-service’ culture, reschedule policies will be written or revised,” says Shorrosh. “Registrars will be in the position of enforcing that policy.”
Presence Health’s financial clearance policy requires authorizations to be obtained for all planned procedures and testing.
“This policy provides the organizational support for patient access staff and leaders to discuss rescheduling of procedures with physicians,” says Hayes.
Patient access staff aren’t expected to determine what services are urgent. Case managers play an important role in making that delineation. “It is helpful to work with clinicians to outline which procedures are always deemed urgent versus those procedures deemed non-urgent, such as screening colonoscopies,” says Hayes.
Patient access consults with case managers only if the need arises.
“The process can be performed defect-free by the patient access staff the majority of the time,” says Hayes. (See related story on proactive approaches to avoid rescheduling procedures in this issue.)
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Stacy Calvaruso, CHAM, System Assistant Vice President, Patient Access Services, LCMC Health, New Orleans. Email: [email protected].
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Amanda Hayes, Regional Director, Patient Access, Presence Saint Joseph Medical Center, Joliet, IL/Presence St. Mary’s Hospital, Kankakee, IL. Phone: (815) 773-7782 or (815) 937-2113. Email: [email protected].
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Wendy Lepp, Corporate Director, Patient Access, Baptist Health System, Birmingham, AL. Phone: (205) 715-5000. Email: [email protected].
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Janice Ridling, Vice President, Revenue Management, Baptist Health System, Birmingham, AL. Email: [email protected].
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Paul Shorrosh, CHAM, Founder/CEO, AccuReg Front-End Revenue Cycle Solutions, Mobile, AL. Phone: (251) 338-3443. Email: [email protected].
