Responding to ACA access problems
Patients presenting with incorrect information
Even if the patient standing in front of you obtained coverage on the Health Insurance Exchange Marketplace, the claim still could end up being denied.
"There are several reasons for this," says Sandra N. Rivera, RN, BSN, CHAM, director of patient access at St. Joseph’s Wayne Hospital and St. Joseph’s Regional Medical Center in Paterson, NJ.
Staff members might be unfamiliar with authorization requirements of the new "exchange" plans. In other cases, payer plan system upgrades aren’t working correctly. "We submit the information via the payer portal as required, but do not get a response back via the portal," Rivera explains. "In those cases, we end up calling the payer to follow up." This process causes delays, due to lengthy hold times.
Some "exchange" plans now require referrals in addition to authorizations. Jill Eichele, CHAA, manager of patient access services at Littleton (CO) Adventist Hospital, says, "This has caused our pre-auth process to take longer in some cases. This could potentially create a delay in getting the patient in for their test."
Many newly insured patients have little or no understanding of what their plan covers or what their responsibility is, says Betty Bopst, director of patient access at Mercy Medical Center in Baltimore. "Patients often do not have their insurance cards with them and have difficulty telling the staff which plan they have," Bopst reports. "Lengthy discussions with patients can cause quite a backup in the high-volume areas."
Some claims are denied simply because staff members don’t read the entire eligibility response. "This occurs when a plan has been terminated or changed, but the information hasn’t caught up with the eligibility system, and the patient hasn’t provided the correct information," Bopst says.
In some cases, patients already have switched to a different plan than their insurance card indicates. "If the member has gone in and out of one of the plans and we fail to obtain authorization, we appeal the denial," says Bopst. "But it is most often upheld."
Registrars at St. Joseph’s Wayne Hospital and St. Joseph’s Regional Medical Center work scheduled cases ahead of time, so payer issues can be resolved before the patient comes in.
"Our goal is to do it correctly the first time," says Rivera. These steps are taken:
• notifying the physician offices if authorization wasn’t obtained;
• verifying with the payer that the authorization is for the correct site, procedure, and date;
• documenting the verification of information and when the physician and patient were notified.
Rivera has worked with the hospital’s director of contract management to resolve ongoing problems with payers’ system upgrades. "The approval logs stopped coming," she says. "We were following up three or four times on the notification of admission."
Rivera set up quarterly in-person meetings with payer representatives, and she ensured she sent information on problems with specific claims ahead of time. "This way, they can research it and bring the outcome to the meeting," she says.
Most patients are unaware that a hospital isn’t necessarily contracted with their particular plan.
"We are trying to do our best to catch them before the patient comes in," says Eichele.
Quality reports were built into the department’s system to catch non-contracted plans ahead of time, for accounts that are pre-registered. "One thing it checks for is certain alpha prefixes in the subscriber policy number," says Eichele. "If that alpha prefix is identified with a certain payer code that we are not contracted with, it hits the report."
Staff members then are able to notify the patient prior to arrival. "This has been especially challenging if patients came to us before, when they had a different insurance," notes Eichele. Patient access staff members must explain why the patient needs to go to a different facility.
Another challenge involves the grace period that patients are given when paying premiums for "exchange" plans. "Their insurance shows as active, even if they are not current with their premiums," explains Eichele. "If they don’t get current, we could see take-backs from the payers down the road."
Access staff now have to ask payers, "Is the member current with their premiums?" when they are inquiring about benefits and authorization. If the answer is "no," staff members discuss this issue with the patients before they come in. If the patients are not current with premiums, patient access staff ask them to sign a waiver stating that they understand that if they do not become current, they would be changed to self-pay status.
"We have also worked directly with payers in addressing some of the issues we had early on," says Eichele. "We have been able to come up with some good solutions."
One payer required the patient’s primary care physician to be called for a referral for a diagnostic test, even though a specialist was ordering the test and the primary care physician already had referred the patient to the specialist. After discussing the problem, the payer agreed that a second referral from the primary care physician was not needed.
"We are able to generate the referral ourselves online," says Eichele. "This saves us a lot of time and a lot of extra phone calls."