EXECUTIVE SUMMARY

Patient access departments are dealing with increasingly numerous and complex insurance plans. About 30% of claims denials at Stanford Children’s Health occur because of incomplete or inaccurate registration. To improve insurance verification processes:

  • provide staff with training;
  • implement technology;
  • identify coverage gaps, or non-coverage, early in the process.

Inaccurate Coverage Info Costly to Organization

Much revenue is at stake, if registrars misinterpret the patient’s coverage.

“Surgical and inpatient services are often $25,000 and up. Given the specialty nature of our care, it is not uncommon for services to cost six and seven figures,” says Andrew Ray.

Registrars at Stephens Memorial Hospital in Norway, ME, were entering insurance information incorrectly into the Epic system.

“My staff were not ‘billers,’ prior to our new computer system,” explains Kelly C. Moore.

Quality assurance staff discovered the problem during quality assurance audits.

“We review what was manually entered into the patient’s chart versus the image of the scanned insurance card, which is kept in the patient’s medical record online,” Moore says.

According to Moore, there were three problems:

  • Registrars chose the incorrect insurance plan.
  • Registrars typed in the incorrect insurance number.
  • Registrars failed to scan the card into the patient’s medical record.

“Re-billing was needed, stalling payment to the hospital,” Moore says. “This crossed over to the patient, who wondered why it wasn’t done correctly in the first place.”

Registrars now consult tools provided by payers, such as examples of insurance cards for different plans.

“These tools are very helpful. We also do rounding with staff as new insurances are uncovered,” Moore adds.

Registrars are required to check their email prior to starting their shift to keep updated on plan changes. For instance, registrars used to document an observation patient’s status only for Medicare.

“Now we are doing this for all payers, to let the patient know they are an outpatient,” Moore notes.

Often, patients don’t understand this when they are in a hospital bed.

“If this document isn’t signed, we could lose revenue for over-the-counter prescriptions,” Moore adds.

Patients and Providers Need Training on Plans, Too

Many have no idea of coverage limitations

Patients don’t understand their coverage. Providers schedule services without realizing the patient’s plan doesn’t cover the provider, the service, or the hospital. Patient access staff are the only ones standing between this scenario and a denied claim, lost revenue, and an unexpected bill for the patient.

“We are coming at it from both angles,” says Stanford Children’s Health Andrew Ray. Here is how patient access departments are educating all involved parties.

  • Patients

Most patients have no idea of the specifics of what their plan covers. They don’t even realize they could be out of network. Emory’s Tinnie C. Garlington, BSB/PJ, CHAM, says, “Most patients view having coverage as if they are able to see any provider in any situation.”

Patients are surprised to learn that certain procedures are not covered, or that procedures were denied due to untimely notification.

“Our goal is to avoid costly denials,” Garlington says.

Stanford’s registrars are expected to answer questions from patients about what a service will cost them, regardless of the plan.

“We still struggle with this, but we are getting better at it,” Ray says, noting that in some cases the patient is the one who has to contact the health plan. “Patients don’t necessarily have the expertise to initiate the request. We’re doing a lot of education on that piece.”

Patient access ask patients to do these two things:

  • Research their insurance before scheduling, especially what the plan covers for that particular service, and whether the hospital is in network.
  • Provide specific details so it’s clear exactly which plan the patient has, instead of just a basic plan name such as “Aetna PPO.”
  • Providers

Clinicians are consulted more often to resolve thorny coverage issues.

“We see this quite often,” Ray notes. “We’ve seen a big shift in the last year, with clinicians being much more involved than ever before.”

This usually happens after a patient gets a big bill because of a high deductible or going out of network.

“Oftentimes, it is the providers who patients feel most comfortable with in venting this frustration,” Ray notes.

Providers have advocated successfully for patients in this scenario by calling or writing the payer.

“In some cases, they have gotten the insurance to cover the services in network,” Ray says.

This is true particularly for specialty and sub-specialty services, whereby the patient may not have any other options in the area. Other times, though, there’s no wiggle room no matter who calls the payer.

“We are basically informed that we’re not considered in network. We are not given a whole lot of choice,” Ray says.

Providers aren’t experts in insurance — nor do they want to be.

“They just want to treat their patients. To have an administration issue limiting or delaying care is quite frustrating,” Ray says.

  • Patient access employees

“There are so many changes, and we have relationships with hundreds of payers and health plans,” Ray explains. “The industry is evolving so quickly.”

Keeping all patient access employees updated is a daunting challenge.

“We have hundreds of registration staff at 65 sites, and another 100 or so at providers’ offices. To get all the information out to everyone is a challenge in itself,” Ray says.

Emory Healthcare’s schedulers as well as its pre-registration and pre-certification teams all receive continuous updates on plan changes.

“Everyone should be knowledgeable on how to communicate the patient’s benefits,” Garlington advises.