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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:
Is the patient’s insurance active? A simple “yes” or “no” once was all patient access had to know.
“Plans used to be more straightforward. Now, we need to do investigative digging,” says Andrew Ray, director of the professional revenue cycle at Stanford (CA) Children’s Health.
About 30% of the department’s claims denials have a root cause of incomplete or inaccurate registration.
“An increasing percentage of those [nearly 40%] are due to not accurately capturing the granular plan details,” Ray adds. “This requires significant rework by our follow-up staff to resolve.”
Here are four problems patient access faces:
“A straightforward registration process takes five to seven minutes,” Ray says. “But the added plan complexity can easily double that.”
This means delays at registration and sometimes in care scheduling.
“The sad result is that it’s added another layer to get through,” Ray notes. “The process becomes longer when we want to provide a quick process for patients.”
Registrars make many more time-consuming calls to payers to discover the details of what’s covered.
“We are having a lot more ‘one-off’ situations, working with payers,” Ray says.
It takes up to 30 minutes to get the needed information. Sometimes, registrars learn that there is hardly any coverage at all, since the hospital is out of network.
“The out-of-network benefits are often close to not having insurance, because the deductibles are so high,” Ray says.
Most patients usually have no idea that their plan has changed, or that a certain service or provider isn’t covered any longer.
“It’s a tough conversation to have with folks, especially when they have existing relationships with our physicians,” Ray laments.
The department has had success in getting plans to make an exception for specialty care and patients in midstream care with an ongoing health condition. In some cases, they’ve been able to prove the hospital employs specialists to handle what the patient needs, while in-network providers don’t.
“We have less success at getting considerations around general routine sick care,” Ray reports.
“This can result in patient bills of hundreds to tens of thousands of dollars, depending on the clinical complexity of the services,” Ray says.
Registrars field some very complex questions about out-of-pocket costs. Frequently, patients express frustration and even anger.
“Quite often, folks are upset with us. I understand where they’re coming from,” Ray says. “In every other business transaction, the financial pieces are fairly well known.”
Patient access is in a difficult spot.
“We are trying to sort out what’s going on with a particular patient. Where they are in their deductible and coinsurance cycle is sometimes unclear,” Ray notes.
Patient access could overstate the potential liability — it’s possible that more of the deductible or coinsurance was met than is apparent — or just wait until everything processes.
“Then we have a potential surprise, which is not good service,” Ray explains. “The solutions we’re left with are not great, across the board.”
Without better education when patients buy insurance, sometimes the best outcome is to “at least limit the surprise a little bit,” Ray says.
The more accurate and complete the insurance information is, the more accurate the out-of-pocket estimate is.
“We make patients aware of financial assistance and payment plan options. They can weigh that versus seeking care elsewhere,” Ray adds.
“Getting down to the extra granularity of detail with the plans we’re dealing with is new over the last couple years,” Ray explains.
Registrars might register the patient as presenting with an in-network plan, failing to realize that it’s a slightly different plan — one that’s out of network with the hospital.
“None of our [systems] trigger us to alert the patient that they are out of network and will have a high out of pocket [expense],” Ray says.
Health plans create a multitude of different networks and products.
“For us, a lot of it is just trying to stay on top of that. It feels like a lot of times we’re playing catch up,” Ray says.
Stanford Children’s patient access department handles about 450 different plans.
“Most of our major payers have added at least one to three new plans,” Ray explains. “With many payers, the number of plans has doubled.”
Patient access is adapting with revamped insurance verification processes, technology, and training.
“We are coming at it from multiple angles,” Ray says.
Plans aren’t always what they appear to be. The sooner patient access realizes it, the better. One frustrating obstacle is that the electronic eligibility data obtained from health plans often are vague and misleading. Ray explains, “Many times the detail is just too high level.”
It’s unrealistic to expect registrars to notice every slight discrepancy in hundreds of plans. Instead, the registration system flags potential problems, such as a member ID or group number, indicating the hospital isn’t in network.
“Within our systems, we’re trying to find ways to flag folks that this is one of the scenarios where we have a different relationship than we used to,” Ray says.
It doesn’t help that patients rarely carry their insurance cards — they expect those to be on file. Tinnie C. Garlington, BSB/PJ, CHAM, manager of financial counseling and quality assurance at Emory Healthcare in Atlanta, says, “Therefore, when their coverage changes, there is a challenge when attempting to identify what type of plan the patient has.”
To address this, the hospital created an insurance verification master committee.
“We work together to identify and solve insurance verification challenges,” Garlington explains.
Recently, the committee tweaked the hospital’s registration system so it notifies users if a plan is non-participating.
“This allows us to have the conversation with the patient regarding how they would like to proceed with their visit,” Garlington notes.
Registrars notify someone on the committee about any plan changes once someone becomes aware of such changes.
“Updates to the system are then made to reduce the issues with patients not being financially cleared prior to arrival,” Garlington says.
Small differences in plan names have been the cause of many claims denials. For instance, the patient may still have Humana coverage, where previously the patient presented with a Humana National POS plan. And although the two plans sound similar, the new plan actually is an HMO.
“We have to be very cautious, because the plan name may change unknowingly to us,” Garlington explains.
At Stephens Memorial Hospital in Norway, ME, if a scheduled procedure isn’t covered by the patient’s insurance, the registration system alerts registrars, who then discuss the situation so the patient can make an informed decision about what to do.
Kelly C. Moore, manager of Stephens’ central registration, says, “The patient has a right to get the services and bill their insurance, knowing it might not be covered, have the test and not bill their insurance, or not get the test at all.”
Very soon, this will happen earlier in the process.
“In the near future, the provider practices will be dealing with the advanced beneficiary notice during the patient encounter,” Moore says. “It will be dealt with at that time either by the provider or by front-end staff.”