Oregon system moves to centralized verification

85% of business to be handled on-line

Insurance verification was a major piece of the puzzle when several acute care facilities formed Providence Health System Oregon and sought to centralize "everything that could be centralized," says Gillian Lawson, CHAM, interim manager of the central access unit.

As part of a project called "Seamless Access Initiative," the health system looked at the whole design of how people access health care to determine the true access functions, she says. "There are now a zillion ways to touch’ us — physician offices, home care, etc. — not just acute care."

Providence grouped the functions and determined which could be performed in a centralized system. As part of the process, a job description was written — patient verification specialist — and combined insurance verification and preadmission functions, Lawson explains. In January, the new patient verification specialists moved from their individual hospitals into a new regional office in Portland.

For insurance eligibility verification, Providence has direct on-line access with its own payer, the Good Health Plan, as well as Blue Cross of Oregon, Medicare, Medicaid, and Kaiser Permanente, Lawson explains. Employees at each work station can toggle back and forth between the on-line payers and other applications, she says. Normally, the payers will give Providence access to a couple of its eligibility screens — "the things they would tell us over the phone" — including such information as eligibility date, copays, out-of-pocket payments, maximums, and per diems.

Another four or five payers will be brought on-line indirectly through Softlink, a software system that manages the information flow with payers that can’t be accessed directly. With Softlink in place, about 85% of the health system’s business will be handled on-line, with the other 15% done the old-fashioned way — through phone calls.

Communication with the payers managed by Softlink will be even more seamless than with the payers with which Providence has direct on-line access, Lawson notes. Softlink gets the information from payers and puts it directly into the fields on employees’ verification screens. Eventually, this will happen with all the on-line payers, she adds. "It’s all being worked out now. It will happen, but I don’t know when."

Having eligibility information at preadmission will allow Providence employees to provide patients with their financial profiles, Lawson points out. The conversations might go like this: "I see your insurance is an HMO, so there’s no financial obligation for you," or, "This is a $100 per day copay, and I see you’ve been authorized for three days. How would you like to pay? Would you like to use your credit card?"

It also provides an opportunity to qualify some patients for government programs or make other payment arrangements, she adds. "If the patient recently became unemployed and qualified for COBRA, we could pick up those premiums if necessary, and have the patient pay it back in small amounts."