The recent expansion of “skinny” health plans will affect patient access. “Patients and providers need to understand the way the coverage in these plans works and that they are not necessarily protected against major medical events,” says Katherine Hempstead, PhD, a senior policy advisor at the Robert Wood Johnson Foundation. There will be more opportunities for insurers to sell short-term or limited duration plans in the individual market because of CMS’ final 2019 Payment Notice Rule. The plans will feature lower premiums but offer less coverage, resulting in higher costs for patients. Many exclude coverage for pre-existing conditions. “Post-claims underwriting is a common practice with these plans, which creates some exposure for providers as well as patients,” Hempstead explains. Inevitably, some claims will be denied after services were provided because the insurance company will argue that the patient’s condition was pre-existing. Also, many plans do not set a maximum out-of-pocket cost. “The impact of these plans will vary by state,” Hempstead notes. “Quite a few states have taken steps to restrict their impact or have banned them outright.”
For Dawn Mickan, BSHA, CHAM, skinny plans underscore the importance of an effective up-front cash collection process. “The final rule should prompt tweaks to existing programs to help patients prepare for higher out-of-pocket expenses,” says Mickan, manager of prearrival services at Sarasota (FL) Memorial Health Care System.
Continual changes in reimbursement and the growth of ambulatory facilities, including surgery centers, also are piling on the pressure. “Hospital-based services are looking for ways to attract patients to their facility,” Mickan says. Offering financial counseling and price estimates are two ways of of gaining patients’ long-term loyalty, both of which are in the realm of patient access. “The goal is to promote a positive patient experience from a financial services perspective,” Mickan says. Recently, Saraota Memorial Hospital implemented some new patient-centered changes:
- Financial assistance program. This addresses the needs of uninsured and underinsured patients who are not eligible for state or federal programs. Additionally, these patients do not qualify for the hospital’s charity assistance program. “Prearrival services and the main registration areas may refer patients with qualifying out-of-pocket levels to this service at any time,” says Mickan.
- The Emergency Care Center (consisting of the hospital’s ED and a free-standing ED in North Port, FL) registration team created a flat-rate option for qualifying uninsured patients.
- Patient access created a benefits coordinators division within the department. After accessing all available financial resources for these patients, benefit coordinators may offer discounts if individuals meet certain qualifications. “If the patient remains unable to make a full payment of discounted charges, a monthly payment plan can be established,” Mickan notes.
- The prearrival and main registration areas use price estimation tools. Staff attempt to contact patients before arriving for treatment. “We help them prepare for their visit and let them know their estimated out-of-pocket responsibility,” Mickan says.
Patients need a great deal of help understanding their financial situation. Patient access has taken on the role of teaching them about billing and insurance processes. “We recognize that patients are in a stressful situation and often don’t understand their coverage regarding deductibles, co-insurance, and copayments,” Mickan acknowledges. Many people assume that because they have insurance, their hospital services should be covered. This is not always the case, of course, so patient access employees sometimes bear bad news. “Our staff strives to approach patients with sensitivity and tact,” Mickan says.
The prearrival department services all outpatient areas, including outpatient surgeries, using a two-step process. First, the team reviews accounts and attempts to preregister and notify patients of their estimated costs at least four days before their visit. Patients undergoing higher-cost services take priority. “Currently, we complete 76% of prioritized accounts,” Mickan says. Second, the insurance verification team also reviews accounts and contacts patients with out-of-pocket estimates above $1,000. The goal is to create an estimate, preregister, and contact 100% of patients. “But it’s an ever-evolving process to find ways reach all of these accounts with a limited number of staff,” Mickan adds.
The department has successfully improved upfront cash collections. More than 2% of net revenue has been collected every fiscal year since 2012. Mickan credits good advance communication with patients. Since staff provide estimates, financial counseling, and information about payment options, patients are more inclined to settle their balance.
“In my department, most of the procedures are elective,” Mickan explains. “We have to be especially mindful that out-of-pocket costs play a role in many patients’ healthcare decisions.” Preservice works closely with billing and collections to eliminate the need for rework on the back end. “We find ways to reduce insurance errors and facilitate a correct and smooth billing process for the patient,” Mickan says.