Easy ways to educate patients on insurance

They know very little about their coverage

Instead of "sticker shock," which refers to being surprised at the high price tag on an item, many patients these days are experiencing "benefits shock" when they learn how little their insurance actually covers.

If patients are unaware of their benefits, care may be denied because a procedure or service did not have a referral or precertification. "There may also be significant out-of-pocket expense for the patient, who is not prepared for the financial impact of medical care. This is particularly true with high-deductible health plans," says Connie Longuet, CHAM, director of patient access services at the University of Texas M.D. Anderson Cancer Center in Houston.

It's just not realistic to expect patients to become experts at the complexities of payer requirements or the hospital's billing processes. However, a little education can go a long way in avoiding misunderstandings that ultimately lead to lack of payment. Here are three strategies used by patient access departments:

• Invite patients to free educational forums.

Susan M. Milheim, senior director of patient financial services at the Cleveland Clinic in Independence, OH, reports that her department is definitely seeing "an increase in confusion for our patients" regarding their insurance coverage.

"As a result, we started patient education programs to help assist patients. These are conducted by our training department, with support from our financial counselors, Medicaid vendors, and Medicare experts," says Milheim. "Financial counselors are another great tool."

The free educational forums cover insurance requirements for surgery, the hospital's billing statements, coverage options for those who have recently lost coverage, how to comparison shop for medical care, insurance terms such as "explanation of benefits," and making the transition from commercial insurance to Medicare.

• Give information to self-pay patients.

To help uninsured patients, registrars at Oshkosh, WI-based Mercy Medical Center give them a "private pay" folder, created by the hospital's billing department. These are handed out whenever a patient is identified during the registration process as having no insurance. "It has the particular patient rep to contact if they feel they need assistance on their bill, and information on the Medicaid program and our hospital's charity care program," says Linda Swanson, registration coordinator. "It's been well received from patients. They see it as us helping them when they are sick or injured and are now going to face a bill."

During the pre-registration process, if a patient is identified as having insurance that is not covered at the facility, Mercy's registrars immediately alert the patient andthe doctor's office. This way, the patient is made aware that he or she is not covered, so they don't face an unexpected bill.

"Many times, we can have the patient switch their Medicaid HMO they are with to one that iscovered at our facility, if they prefer to use us for their care," says Swanson. "We can have it done prior to their arrival, so there is no loss of revenue for the system or financial burden for the patient."

If an obstetrics case comes up as a non-contracted HMO for the facility, for example, the case worker is typically able to switch the patient's coverage to a different HMO. "So by the time their delivery came, the patient was able to deliver here and continue to receive prenatal care with one of our OB doctors," says Swanson. "Otherwise, the patient would have to go to another facility or the hospital would not have gotten payment, nor would the patient like getting that large bill."

• Create a form to review insurance coverage.

"The sooner the patient is advised of their financial liability, the better," says Milheim. "Communication with the patient at the time of scheduling, not post-service, is ideal."

In order to ensure patients are aware of their insurance coverage beforehand, patient access staff at M.D. Anderson review a patient's insurance at the time of registration. "We find that patients are almost always unaware of all the elements of their coverage," says Longuet. "We designed an insurance coverage summary form that we complete and review with each patient. The form lists copays for physician, emergency center, and inpatient visits. It discusses deductibles, both inpatient and outpatient."

The form also reviews pre-existing limitations, lifetime maximums, and annual maximums. "Because we see patients from all over the world, we may not be contracted with an insurance company. So we also review the in-network and out-of-network status," says Longuet.

If the patient still has questions after the form is reviewed, patient access staff phone the insurance company with the patient present. This ensures that everyone has the same understanding of the insurance coverage. 

The form is only used at new patient registration, or as needed when meeting with existing patients. "It would be way too much to keep up with each time every patient's insurance changes," says Longuet. "While this process lengthened our registration times to about 30 minutes per patient, both the institution and the patient benefit greatly in the results of this effort."

As many of the hospital's patients come daily or weekly to receive services, explaining their insurance coverage allows them to prepare financially for the future visits. "Explaining deductibles and copays at the beginning reduces the surprises on subsequent visits," says Longuet.

[For more information, contact:

  • Connie Longuet, CHAM, Patient Access Services, The University of Texas M.D. Anderson Cancer Center, Houston, TX. E-mail: clonguet@mdanderson.org.
  • Susan M. Milheim, Senior Director, Patient Financial Services, Cleveland Clinic, Independence, OH. Phone: (216) 636-7210. Fax: (216) 636-8088. E-mail: milheis@ccf.org.]