Access Management Quartertly

Make staff aware of payer requirements

You can't afford these mistakes

Automobile and accidental injury regulations, the Medicare as Secondary Payer questionnaire, and workers' compensation guidelines are just a few of the many issues with which the patient access professional and case manager must be educated and competent.

With today's health care insurers varying notification requirements, failure to notify the proper plan will result in a denial that cannot be billed to the patient. Many hospitals cannot afford to have too many of those mistakes.

"Considering one observation stay could cost anywhere from $2,000 to $20,000, the monetary effects of not getting an authorization could be substantial," says Donna Swift, CHAM, patient accounts manager at Hillsdale (MI) Community Health Center.

To avoid those costly errors, a complete registration interview must be conducted, with eligibility and benefits verified concurrently with the admission. "This is becoming increasingly important for health care access professionals," she says. "Trying to keep up with all of this, as well as educate the affected employees, can be a real challenge."

Swift says she recently reviewed with staff individual payer rules, phone etiquette, and all the various payer web sites. To keep employees current with all the rules, regulations, and notification requirements, She says she reads payer bulletins, monitors their web sites, and establishes a good rapport with their representatives.

At Hillsdale, the registration clerk verifies benefits, eligibility, and any other coverage information as appropriate. "This way, the case manager is not spending time on the phone with a company that doesn't require clinical information," says Swift.

"Emphasize the importance of complete patient registration interviews," she says. "Make sure that any accident or injury insurance information is gathered and verified along with the health insurance."

The registration clerk is responsible for notifying the insurance plans that require immediate notification, and the case manager is responsible for then notifying the other plans, as well as calling in necessary clinical information.

However, sometimes a plan that requires immediate notification could be missed if the registration clerk isn't aware of the requirement. By the time the case manager calls, it may be too late to get the authorization.

Swift recommends training the registration clerk as to what information the case manager needs. If case managers can spend less time on the phone communicating nonclinical information, they are able to focus on patient care-related issues. "Both play a vital part in the revenue cycle and should understand the importance of the role that they play," she says.

An alternative method is that the clerk not only verifies benefits and eligibility, but also starts the precertification process before the information is delivered to the case manager.

"The case manager is then notified of what the plan's requirements are, and clinical information can be called in as appropriate," says Swift.

(For more information, contact Donna Swift, CHAM, patient accounts manager, Hillsdale Community Health Center, e-mail: