Executive Summary

Patient access staff can interpret responses from insurance eligibility software incorrectly, causing lost revenue. The following tips can help prevent mistakes.

  • Create an in-service for new hires on interpreting the responses.
  • Post information on eligibility responses on the hospital’s Intranet.
  • Ask staff to alert managers if a payer’s response looks unfamiliar.
  • Involve the managed care department for problems with payers’ responses.

Automated insurance eligibility tools make a tiresome task quick and easy for patient access employees. However, responses can be surprisingly difficult to interpret.

At Ohio State University Wexner Medical Center in Columbus, patient access uses a manual process for a small number of payers without the ability to verify transactions electronically. “You either collect a copy of the insurance card or call the payer to confirm eligibility,” says Kathy Herrick, manager of registration quality assurance.

For most payers, an automated eligibility tool is used. “It’s a good tool, but the problem is that you don’t always get consistent responses. That is challenging,” says Herrick.

The electronic response is not always clear cut. It can be difficult for employees to interpret. “You’d think it would be as clear as a ‘yes/no’ answer. But it’s not always that way,” says Herrick.

If eligibility responses are interpreted incorrectly, claims denials are inevitable. To address this, the department made these changes:

  • Revenue cycle trainers created an “Advanced Insurance and Eligibility” course.

The four-hour in-service for new hires covers the basics of eligibility responses, plan selection, effective dates, and guarantor accounts. Staff are also given helpful information on specific payers.

“All staff working with insurance or registration are required to complete this class. It’s dedicated to looking at eligibility responses and interpreting them,” says Deb Wharton, manager of revenue cycle training.

  • The department posted insurance coding information on the intranet.

After clicking on a specific payer, registrars can view a sample insurance card and sample eligibility response. “By looking at examples, staff can better understand how to code and how to select the appropriate payer and plan,” says Wharton.

Unexpected Changes

Eligibility responses don’t always look as staff expect them to. “An example would be an alert telling you to change an insurance plan code, but the information in the response does not identify with that plan,” says Wharton.

Sometimes confusion occurs because of something the payer changed without notifying the hospital. For instance, an employee group number may have changed. “Unannounced changes are challenging,” says Wharton. “We alert staff with a blast email.”

If staff notice something that does not seem quite right, they are encouraged to alert managers immediately. “Front-end staff will certainly see things quicker than we will,” says Herrick. “We have to rely on them.” For example, registrars may complain, “Every time I put this through, we are getting this response from the payer — but we never used to. What’s going on?”

It might be necessary for someone to speak with a payer directly. If that’s the case, the hospital’s managed care department gets involved. “We also use a third-party eligibility vendor who has extensive payer contacts. Depending on the issue, we may work with both,” says Herrick.

Sometimes the problem is that the payer’s website has different information than the electronic eligibility tool is giving. “We do find that occasionally, and we then have to work with the payer to rectify it,” says Herrick. Last year, a payer was denying eligibility for members of an employer group because the employer gave the payer incorrect information for the payer’s set-up. “There were lots of denials, which resulted in a call with the payer,” says Herrick.

SOURCES

  • Kathy Herrick, Manager, Registration QA, Ohio State University Wexner Medical Center, Columbus. Phone: (614) 293-7669. Email: Kathy.herrick@osumc.edu.
  • Deb Wharton, Manager, Revenue Cycle Training, Ohio State University Wexner Medical Center, Columbus. Phone: (614) 293-2002. Email: deb.wharton@osumc.edu.