Many more patients are receiving an unpleasant surprise: Their coverage is out of network. This coverage means high deductibles, out-of-pocket maximums, co-insurance amounts, or no coverage at all.
“The decision to go out of network is either very costly or not an option at all,” says Angie Bustamante, CHAA, team lead for financial clearance for the Patient Access Center at Sutter Shared Services.
For example, it’s not uncommon for out-of-network patients to face a $6,000 deductible or higher before co-insurance of 50% begins.
“The high deductible for out-of-network benefits is so financially taxing, the patient has very little choice,” Bustamante says, noting some patients end up going to another hospital for surgery, even though the ordering physician is in-network. “The question that we should be asking is, ‘Why even have out-of-network benefits if the patient can’t afford to use them for elective procedures?’”
Sutter Health’s financial clearance team members determine if the insurance is out of network as early as possible.
Usually, this coverage is determined shortly after the service is scheduled. Financial clearance team lead Raye Deleurme, MBA, CHAA, says, “That could be anywhere from 24 hours to four weeks in advance of the date of service, depending on when it populates in our work queue.”
Registrars also look for limited benefit plans, or benefit limitations that exclude certain procedures, such as total hip or total knee replacements. Any of these things could result in a denied claim.
“This allows for timely notification to the provider and the patient, giving the opportunity for the service to be scheduled in a participating facility,” Deleurme says, adding that it’s also an opportunity for patient access to educate the physician’s office. “Just because the physician is contracted does not mean the facility they book the patient service at will also be part of the patient’s in-network benefits.”
Registrars reach out directly to the surgery scheduler at the physician’s office and as if they’re aware the patient is out of network at the hospital. If not, the registrar explains why the patient’s coverage is not contracted.
“In addition, we explain the potential negative financial impact to the patient, compared to using the patient’s in-network benefits,” Deleurme says.
Usually, the surgery schedulers are not aware that they have scheduled the patient at an out-of-network facility.
“The unintentional error occurs because the physician is in network, so the patient is scheduled at the hospital the physician has privileges at,” Deleurme says.
Patient access leaders at Nemours Alfred I. duPont Hospital for Children created a new process to address patients with out-of-network coverage. Stacy Hutchison-Neale, CRCR, supervisor of the hospital pre-authorization department, says, “This new process will be a totally transparent approach.”
With the new process, all four Nemours sites now handle non-participating patients the same way. Previously, each area had limited knowledge of insurance coverage.
“This only upset the family and associates more,” Hutchison-Neale explains. “Not everyone knew how to answer the questions that families asked.”
Ultimately, it’s the patients’ responsibility to know and understand their insurance coverage.
“But most are unaware of their benefits and out-of-pocket responsibilities,” Hutchison-Neale adds.
Registrars don’t wait for something to be scheduled before finding out the hospital is out of network.
“Previously, we would schedule follow-up patients with no lead time,” Hutchison-Neale says.
This system resulted in very frustrated families if procedures had to be rescheduled. Also, out-of-network families were scheduled without knowing how much they’d owe.
“Services would be rendered, and they received a large bill, which they were not expecting,” Hutchison-Neale notes.
Now, registrars inform families of their benefit amounts before giving them the option to make an appointment, using this process:
- New patients are directed back to their physician’s office so an authorization can be obtained for the services by the primary care provider.
“If the patient has out-of-network benefits, they ask for a prior authorization for services to take place at a non-participating provider,” Hutchison-Neale says.
If they have no out-of-network benefits and the primary care provider is unable to obtain an authorization, the registrar refers the family to a participating provider.
Once the authorization is in place, and the insurance company provides a single case agreement, patient access contacts the family to schedule the appointment.
“If for any reason there is a denial, the family is notified,” Hutchison-Neale adds.
- Existing patients are allowed to make an appointment, but it’s scheduled far enough in advance to obtain authorization and a single case agreement.
The discussion about out-of-network coverage starts at the first contact with the family.
“This prevents false expectations and disappointment,” Hutchison-Neale says, explaining that previously, scheduled appointments had to be cancelled.
Patient access staff are given classroom training on out-of-network coverage.
“We provide the family with their exact out-of-network benefits, including deductible, coinsurance, and copays,” Hutchison-Neale says.
Registrars also make them aware of in-network benefits. The family members can make an informed decision if they still want to proceed with a non-participating provider.
“This is a full-on approach to training,” Hutchison-Neale explains. “We want everyone fully capable of answering questions from families.”
Exceptions Are Possible
In some situations, payers sometimes allow services to be paid as though they were in-network.
“If a maternity patient is in the second or third trimester, the insurance reimburses at the old contracted rate,” Bustamante says.
Exceptions are sometimes made if patients have to travel significantly farther to the nearest in-network hospital.
“If the out-of-network location is in the best interest of patient care, a letter of agreement is secured,” Bustamante says.
The determination can be quick for some of the larger insurance plans.
Deleurme says, “However, an independent insurance plan or a less common insurance plan can become very time-consuming, because we have to call the insurance to verify if we are contracted.”
In the first eight months of 2016, 1,049 single case agreement requests were submitted to Nemours’ managed care department.
“There are certain insurance companies that will not negotiate single case agreements, since we are non-participating,” Hutchison-Neale notes. “But we still try by requesting them.”
Sometimes “continuity of care” exceptions are made for patients that have seen the provider for a prolonged time.
“However, they may only provide a limited amount of approval for the appointment, so that the patient can be transitioned to a participating provider,” Hutchison-Neale says.
Some payers make “gap exceptions” if patients are travelling long distances to the in-network provider.
Timing is another obstacle. “Some insurance companies take 51 days from the request date to close a single case agreement request,” Hutchison-Neale warns.
Families can consult with one of Nemours’ authorization specialists about their out-of-network status.
“But we are limited with what we can do, since the insurance company has decided to not participate with the facility,” Hutchison-Neale adds.
If the family still wants to be seen by the non-participating provider, patient financial advocates assist with payment options.
“If they do decide to move forward, there won’t be any surprises,” Hutchison-Neale says.
- Angie Bustamante, CHAA, Team Lead, Financial Clearance, Patient Access Center, Sutter Shared Services, Roseville, CA. Phone: (916) 297-9202. Email: [email protected].
- Raye Deleurme, MBA, CHAA, Financial Clearance Team Lead, Sutter Shared Services, Roseville, CA. Phone: (916) 297-9104. Email: [email protected].
- Stacy Hutchison-Neale, CRCR, Supervisor, Hospital Pre-Authorization Department, Nemours Alfred I. duPont Hospital for Children, Wilmington, DE. Phone: (302) 651-5184. Fax: (302) 651-4224. Email: [email protected].