The trusted source for
healthcare information and
The growing trend of “narrow” networks means patient access must inform an increasing number of patients they’re out of network. To address this:
The patient is ready for a scheduled service, the provider has completed a valid order, and all systems are “go”— that is, until the registrar discovers the hospital is out of network.
“We are finding insurance companies are really cracking down — and requiring their members to seek care based on a certain list of providers and hospitals,” says Brenda A. Mulligan, MBA, CHAM, director of access management at Eastern Maine Medical Center in Bangor. Patients who decide to ignore payer requirements and seek care at the hospital anyway incur steep costs — sometimes, the entire bill.
“We are finding insurance products being sold with limitations in the member’s coverage have been increasing,” Mulligan explains.
Plans bought through the Health Insurance Marketplace are the usual suspects.
“A year ago, we may have had one or two plans that required an out-of-network referral,” Mulligan says.
A new wrinkle: Several new exchange plans cover specific geographic counties. If the patient seeks services outside the geographic region, the hospital automatically is considered out of network.
The department’s insurance verification software helps by alerting employees if they are pre-registering a patient who is out of network. The patient is notified right away.
A few patients don’t learn the bad news until they present for services.
“Unfortunately, the patient is informed the care they will be receiving is not covered, or it may need an out-of-network referral based on the insurance plan,” Mulligan laments. Probably the worst scenario is if the out-of-network status goes undiscovered.
“The claim will be denied. The patient then receives the bill for the services performed,” Mulligan adds.
Registrars are in the unenviable position of telling patients — some of whom have gone to the hospital for many years — they’re no longer in network.
“We have been using scripting to inform patients when they are out of network,” Mulligan explains.
If patients need additional information about their coverage, registrars refer the patients to their insurance company.
Jacqueline Chevalier, a pre-registration access associate, recently saw an alert stating that a patient’s coverage was out of network. She immediately explained the situation to the patient.
“She was so grateful we let her know ahead of time so she could address the situation and decide whether or not to have the MRI at our hospital,” says Chevalier, who then referred the patient to a financial counselor.
Most out-of-network patients choose to cancel the planned procedure and go to another in-network facility. Some want to know how much it would cost to continue before making the decision.
Financial counselor Makenzie Lugdon, CHAA, says, “When we come across a patient who has insurance that is out of network, we complete an estimate for the service they are coming in for.”
In some cases, the patient’s plan covers only certain counties, meaning the service won’t be covered at Eastern Maine Medical Center.
“The cost of the service would then be the patient’s full responsibility,” Lugdon adds.
Bridget Puryear, regional director for patient access at Hagerstown, MD-based Trivergent Health Alliance, a management services organization providing regional healthcare services for three Maryland hospitals, says, “We try to obtain as much information as possible from our patients and providers prior to scheduling services.”
Real-time insurance eligibility is an important tool, paired with price estimation software that can calculate the cost of out-of-network benefits based on an estimate of charges. “More information is available earlier in the process,” Puryear explains.
Preregistering patients allows Eastern Maine Medical Center’s registrars to identify out-of-network plans early in the process.
“The sooner we can alert patients the services they will receive are out of network, the better the patient’s experience,” Mulligan notes.
Some patients are relieved to find out their care won’t be covered by their insurance beforehand.
“That being said, we have had some patients where we did not know their plan was out of network, and the claim was denied,” Mulligan recalls. These patients received a surprise medical bill and were frustrated to learn they had little recourse.
“It’s a tough conversation to have with a patient when you explain their insurance company will not cover the provider — or, in some cases, the hospital,” Mulligan says.
To add to the frustration, the payer’s out-of-network status can be tricky to pinpoint.
“We are challenged identifying some payers as out of network when they don’t use unique identifiers as part of their policy numbers,” Mulligan notes.
If patients don’t know the limitations of their insurance coverage, they can’t make an informed decision. “Patients deserve to know if the quality care they are seeking will not be covered by their insurance company,” Mulligan underscores.
Most out-of-network patients cancel their services; some opt to delay their scheduled care in the hopes something can be worked out.
“We have had some patients reschedule their services while they contact their insurance company to see if they can get the service covered,” Mulligan says.
It is rare for payers to make exceptions for out-of-network patients.
“But we have been successful in a few cases,” Mulligan reports. “For several bariatric surgical cases, we were able to get an out-of-network referral to the surgeon.” The surgery was authorized.
Another patient was admitted on an emergency basis for orthopedic surgery. The patient needed to come back for an additional surgery, and the insurance company wanted the patient to go to an in-network provider.
“The surgeon became an advocate for the patient, and received approval from the insurance company to have the surgery performed by the same orthopedic surgeon,” Mulligan says.