Patients often fail to tell patient access if their coverage changes, and eligibility verification software responses do not always catch it. Taking the following steps can help prevent claims denials.
- Make scheduling aware of the payers’ out-of-network statuses.
- Provide training in interpreting eligibility responses.
- Be sure patient access staff know what to do if they find errors.
When a patient changes insurance in the middle of treatment, he or she won’t always tell patient access. Claims denials are likely to follow.
“The new insurance might have different authorization requirements,” says Aimee Egesdal, patient access manager at Genesis Health System in Davenport, IA. This unexpected glitch will delay the patient’s scheduled service.
The department uses an eligibility system to verify the patient’s coverage. “If it comes back not eligible, it allows the registration staff to have a further conversation with the patient prior to moving on to their test or procedure,” says Egesdal.
If the new payer is out-of-network, patient access educates patients about what this means for their care. The patient is asked to sign a waiver stating that they were informed that some services might not be covered. “Sometimes the patient chooses to cancel,” says Egesdal.
Patient access collaborates with the scheduling department to head off claims denials. The patient’s service might need to be rescheduled or even cancelled altogether. “We make them aware of the payers’ out-of-network status, and they can try to ‘stop the line’ at that point,” says Egesdal.
If a patient’s previous insurance is now inactive, eligibility verification software should catch it. Patient access employees don’t always interpret the response correctly, however.
“We have found that most errors are due to a lack of more detailed training,” says Jill Eichele, CHAA, corporate manager of patient access at Centura Health in Englewood, CO.
Electronic responses look different depending on the payer. This causes confusion when staff try to interpret the responses. “Specific benefits are shown in different sections, depending on the payer,” says Eichele. For example, when looking for an ER benefit, one payer may show it in an “Emergency Room” section, while another payer shows it in a “Hospital — ER” section.
“It’s important to look through the whole response to ensure you are pulling the data from the correct section,” says Eichele.
The department created training specifically to teach new patient access hires how to read eligibility responses. Existing employees also get the training, in the form of webinars.
“We used Skype for Business for the live sessions. Users across the system can call in and follow along on the screen,” says Eichele. Patient access leaders also recorded a PowerPoint presentation, and loaded it into the hospital’s education website. “Managers are able to assign it to associates who are struggling. Associates are also able to self-enroll,” says Eichele.
The training covers these areas:
- What all of the different eligibility responses look like
“We guide users on where to look for specific information,” says Eichele. “We remind them that they need to look beyond just ‘active,’ or ‘inactive.’”
“Active” refers only to the status of the policy. “However, by reading the response, you may be able to determine that it’s a non-contracted plan,” says Eichele.
Just because the policy is active doesn’t mean the plan is in-network. “It may not be a plan that is accepted at your facility for elective services,” says Eichele.
- What it means if the response shows errors or mismatches
“Some issues can be wrong subscriber listed or replacement plans being returned,” says Eichele.
The Regional Care Collaborative Organizations (RCCO), which are part of Colorado’s Medicaid program, are another common cause of confusion. “We often get a mismatch when we run regular Medicaid, and the eligibility tool alerts us that the patient is part of an RCCO,” explains Eichele.
Patient access also can tell if there is additional coverage. “We run Medicare for a patient, and the response alerts the user the patient has other coverage,” says Eichele. This may be a Medicare Advantage plan or a commercial plan.
- What to do when staff see these responses
Patient access has to consider all of the information that comes back. This includes the group name, the plan information (HMO, PPO, or EPO), other coverage the patient may have, and coordination of benefits.
“There is often a lot of good information that will help them determine the correct coverage to select,” says Eichele.