Laying groundwork crucial to electronic verification

Bringing local carriers on-line is one step

As hospitals continue to push business operations to the front end, access managers seek new forms of technology to help them deal effectively with the additional functions and responsibility that move entails.

Automated electronic verification of patients’ insurance benefits is coming to the fore in recent months as one time-saving solution for overburdened access departments. An increasing number of software vendors are offering a way to do more work with less staff while speeding up the reimbursement process.

But as the vendors come in to show their electronic verification wares, it’s important to be aware of the preparation necessary before such a system is up and running, says Joseph Denney, CHAM, lead for the patient management system implementation at The Ohio State University (OSU) Medical Center in Columbus.

"There are several things that should happen simultaneously," Denney says. His hospital is in the midst of bringing up a new patient management and accounting system as well as a new clinical system, and will follow that with the installation of an electronic verification system from Healthcare Data Exchange (HDX) in Malvern, PA.

"When the [software] vendors come in, if they don’t already have clients in your area, there is lots of groundwork to be laid," he points out. "They might say they have national carriers such as Travelers and Aetna on board and some sort of deal with Medicare, but how about — in our case — the Ohio Department of Human Services? That vendor has no access to Ohio Medicaid right now, so a deal needs to be worked out with them."

Major local insurance carriers likely would not be part of the software company’s national system, he says. "The carrier that handles all of our insurance for OSU, for example, is a local company that does not have a contract with HDX. But because this company covers all of the OSU employees and their beneficiaries, it’s a significant amount of our business. If those employees choose the PPO [preferred provider organization] product, they have to come to us for health care services."

If vendors such as HDX can’t work out such issues, they can’t continue to sell their product, he says. And it’s to the local insurance company’s advantage to cooperate. "They’ve said, We would much rather not get that telephone call [asking for manual verification] that you don’t want to make,’" Denney says.

Such cooperation notwithstanding, the parties still must come to the table to negotiate the details, he says. "The carrier could have some financial outlay upfront, but in the long term, that could be offset with savings in employee time. [The hospital] is a third party in laying the groundwork. It is to our benefit to see that it occurs, so if a middle man is needed to get these groups to the table, we need to do it."

Another factor to be considered, he says, is whatever modification might be required of the patient management (registration) system. "We set up the patient management system at the model level, what routinely would be installed at other institutions," he explains. "That means our insurance screens are at a certain point in the registration pathway when it would be too late to enter data into the system and get it back before the registration is finished."

That means, Denney adds, that hospital programmers must make changes in where those screens lie, to put them near the front of the pathway. When those changes are made and the system is in place, there will be an interface with HDX that is totally non-viewable to the registrar, he explains. "The registrar doesn’t have to enter additional information, execute a special command, or enter another screen to initiate the verification process. It’s seamless and can be built into the pathway."

Besides performing this function during the actual registration process, patient access services personnel also place precertification telephone calls for elective admissions and surgery cases following the manual calls to obtain insurance verification, he says. "The new system will eliminate one whole step of this process, too."

Denney estimates that OSU’s insurance verification system will go on-line sometime after Jan. 1, 2000, because of the priorities of year 2000 testing. For those considering such a system, he emphasizes the importance of advance planning: "Don’t let it get too many months down the road before you start doing some of these things."