Registrars contend with dozens of health plans, some of which are almost exactly alike. Those details mean entire claims are denied.
“There are so many logos on insurance cards today, it is difficult to determine who is the core payer. The largest logo does not always win,” says Pamela Carlisle, MHA, FHAM, director of revenue cycle management at Genesis HealthCare System in Zanesville, OH.
The department created an education class specifically for insurance. Trainers use actual physical cards to teach registrars to tell them apart. They also review the details of the coverages and subtle differences between government and commercial plans. “Pulling staff away from the team, and taking time just to talk about insurance cards, truly improved the quality of their work,” Carlisle reports.
Patient access trainers give frequent updates — again, using visuals of problematic insurance cards. “This allows the selection of the correct insurance,” Carlisle notes.
For years, registrars at Hackensack (NJ) Meridian Health struggled to keep track of all the look-alike plans. No matter how careful they were, mistakes were made because processes were mostly manual.
“Each payer has multiple product lines, and employers all have different benefits,” explains Anne Goodwill Pritchett, MPA, FHFMA, senior vice president of revenue cycle operations. Registrars might enter the correct plan, but the wrong product line. They selected HMO instead of PPO, or vice versa. Staff were not careless or unprepared. “Everyone knows what the terms HMO and PPO mean. But on the card it may have used some other language that is not as familiar,” Goodwill Pritchett suggests.
The mistakes caused major problems for the revenue cycle. “There were discrepancies between what we had anticipated as the expected reimbursement and what the payer actually paid,” Goodwill Pritchett reports. Health plans negotiate different rates depending on whether the plan is an HMO, PPO, or indemnity. If the wrong option is selected when the claim is submitted for payment, the contract management tool calculates the expected reimbursement for the chosen product line. If staff select an HMO with expected reimbursement of $5,000, but the patient really presented with an indemnity plan that offered reimbursement of $6,000, the payer would pay the $6,000.
The payer was meeting contractual obligations for the selected plan. Yet the hospital’s system only expected to receive $5,000 from the payer, since HMO was selected incorrectly. In that kind of confusing situation, it seemed like the payer overpaid by $1,000. “That would create a credit balance in the system,” Goodwill Pritchett notes.
It also worked the opposite way. If staff chose PPO, but the patient actually presented with an HMO, the payer situation would pay $5,000. It looked like the payer still owed $1,000. “That’s why choosing the correct product line in the first place is so important,” Goodwill Pritchett stresses.
Denials also happened because it turned out the patient’s coverage was not active on the date of service. “We were relying on individuals to make phone calls to verify coverage. Maybe the registrar didn’t always update the coverage correctly,” Goodwill Pritchett suggests.
Most of these hassles were resolved with an insurance verification tool. Registrars no longer have to keep track of scores of plans and product lines. “Due to the complexity of coverage, we use technology extensively to confirm benefits and eligibility,” Goodwill Pritchett says.
The department lowered claims denials to an absolute minimum. “We find out, in seconds, whether the patient is covered, the benefits, and the patient’s responsibilities,” Goodwill Pritchett says.
Registrars see how much of the deductible was met already. Guesswork on whether the plan is an HMO, PPO, or something else is eliminated. If the patient carries an out-of-network benefit, it is displayed, too. “Our goal is to make sure we have the correct information to minimize denials,” Goodwill Pritchett says. Not all health plans can be retrieved through the online application. For smaller plans (such as workers’ compensation and some no-fault payers), staff turn to payer portals to verify coverage.
“As a last resort, we call. But our calls are really at a minimum,” Goodwill Pritchett says. The department’s biggest challenge has become the constant coverage changes health plans make. Whenever something changes, training is needed. “The training depends on the type of change it is,” Goodwill Pritchett says.
If it is a simple change, such as adding a new payer plan or a payer identifier for a new product line, the trainer sends an email to all the appropriate team members. If it is something more complex, a “learning dashboard” is created for staff to refer to at any time. Formal training is conducted only for major changes, such as a system upgrade (previously handled in-classroom; now handled through WebEx).
Eligibility-related denials are rare, but medical necessity denials are cropping up. “With certain types of services, payers want a letter of medical determination,” Goodwill Pritchett says. If patients are coming in for an elective service, payers want all the clinical documentation in advance, or they will not approve the service. If a patient is admitted through the emergency department, an electronic notification is sent to the payer. If clinical data are needed, then case management is notified electronically — and it is sent quickly and documented in the system.
“Even there, we are using technology to improve processes that were very manual,” Goodwill Pritchett adds.