Many patients misled on coverage, but patient access staff can help
Plans with $20,000 deductible in marketplace
Patient access employees probably believe that insurance companies have an obligation to fully inform consumers about the coverage they're getting. Unfortunately, this belief doesn't always translate into reality.
"It's easy to say that the payer should be doing this, and most do try hard to explain. But as benefit plans get more complex, members don't often fully understand their benefits," says Jen Nichols, senior director of revenue cycle operations at Kaleida Health in Buffalo, NY.
Nichols is seeing plans with an out-of-pocket maximum in the tens of thousands. "Unfortunately that is not uncommon these days. Where in the past a patient might have had a $2,000 maximum, now $20,000 plans are in the marketplace," she says. "Folks used to having a more robust benefit package are trying to adjust to this new reality."
Patient access employees at Ochsner Health Systems Baton Rouge (LA) Region are seeing an influx of patients with plans ranging from major medical, limited medical, mini-medical, micro-medical, and medical discount. "These plans advertise themselves to the public as 'innovative,' but really, some are only good for catastrophic purposes," says Elizabeth H. Broadway, CHAM, director of patient access and business services.
Access reaching out to patients
Patient access staff must step up to fill the role of informing patients about their coverage, argues Nichols.
"For the last several years, having a really robust pre-arrival department was considered a best practice," says Nichols. This best practice means that patient access intervenes just prior to scheduled services or sometimes when patients are shopping for quotes.
This step is still important to do very well, she says, but Kaleida's patient access employees are taking it a step further. "There is a role for us to play in helping patients to understand their benefits even before the patient has presented on the pathway to services," says Nichols.
Financial counselors, called "navigators," now provide outreach in the community to assist patients in enrolling in Medicaid and exchange plans, even prior to needing healthcare services. Nichols says the outreach makes it less likely patients will present for catastrophic and costly events, since they'll presumably be getting better preventative care. "This will help patients to be healthier ahead of time, so they hopefully don't need us for a costly, catastrophic illness that may put both their personal finances, as well as hospital revenue, at risk," she says. If patients do present for a catastrophic illness, they will have the security of having some level of coverage to assist them.
Previously, patient access were stuck in a "reactive" mode, says Nichols. Staff waited for a patient to contact them or waited for a physician to refer them, before helping them to obtain coverage or understand their existing coverage. "We now have an opportunity to be proactive, to help patients enroll even before they need us. So when they do need us, they are well-covered," says Nichols. "That takes the anxiety off the patient. It is one less thing to worry about."
If patients present for services without insurance, the financial navigators still help them to apply and enroll in traditional Medicaid or any of the nine plans available through the state's exchange.
"We are not an insurance broker and we make no profit on this," Nichols explains. "We are trying to help patients sign up early for coverage and connect them with the right coverage plan."
Earlier is better
Whether patients are presenting for services, or do not need coverage yet, patient access employees take the approach "the earlier in the process, the better," says Nichols.
Employees use an internally developed application to provide accurate, timely quotes to patients. "Resolving finances early on reduces stress on the patient. It also clearly reduces our cost to collect," says Nichols.
If no one educates patients on their coverage, it causes problems for the patient and the hospital, due to a longer time to collect, increased bad debt, and less reimbursement, says Nichols.
"Then there is the goodwill factor," says Nichols. "It's hard to quantify that. But if we are upfront with patients, they might not like what we tell them, but they believe we are a committed partner with them."
At Mercy Hospital in Springfield, MO, some patients consider cancelling surgery due to high out-of-pocket amounts. "We offer a low-interest bank loan and payment arrangements to enable them to go ahead with surgery," says Rebecca Holman, CHAM, patient access manager. (See related stories below on what questions to ask patients at preregistration, how to determine if financial counseling processes are getting good results, and good processes to help patients.)
Ask this question at preregistration
Would you like to speak to someone about financial concerns?" This question is one of the most important ones to ask patients being preregistered, according to Jen Nichols, senior director of revenue cycleoperations at Kaleida Health in Buffalo, NY.
"Giving them the opportunity to speak with a financial counseling staff is the single best way to get them to understand their responsibility," she says. If patients have financial concerns or might qualify for assistance, staff will help them understand their options and apply.
There are many different resources for low-cost or free care that staff can connect patients with, in addition to traditional Medicaid or charity care, such as grants or free screening examinations provided by community organizations. "Patients need to understand we want them to get coverage as much as they do," says Nichols.
Offering prompt pay discount or extended payment plans are other ways to assist patients who have coverage but large patient responsibilities.
"It's certainly not mandated across the nation that hospitals have to offer discounts for patient responsibility after insurance," notes Nichols.
However, if you don't offer these options, a patient who is shocked to find he or she has a $20,000 deductible might end up paying nothing.
"We can't go back and unwrite a contract that they've signed," says Nichols. "But at least you can take the immediate crisis away from the patient."
Finances are a top priority for access
Unfortunately, healthcare costs are often the first thing that comes to mind when someone gets sick, says Elizabeth H. Broadway, CHAM, director of patient access and business services at Ochsner Health Systems Baton Rouge (LA) Region.
"We can counsel patients on the costs and financial expectations during the pre-registration call, but the resources are limited for the population that is underinsured," she says.
This issue results in increased cancellations at the point-of-service and high levels of frustration for the patient, due to a lack of other financial options, she reports. "Louisiana is one of the only states left that has an 'organized' charity care system," says Broadway. "Unfortunately, this is where the patients have traditionally ended up."
For these reasons, patient access staff members have made financial counseling a top priority. "This has become a staple item of our healthcare system," reports Broadway. "We advocate that the patient must be given the opportunity to make a detailed and informed decision regarding the financial aspect of their healthcare."
Patient access representatives take these steps:
• They sit with the patients in a private, confidential area to discuss what their needs are and what resources are available. This meeting occurs prior to their scheduled visits or at the day of their scheduled encounters.
• They explain the patients' current coverage and educate them on how the benefits will work.
Staff members begin by stating what the benefits are and then ask the patients if they are aware of the limited coverage provided by the plan.
"From there, we identify what the financial gaps are. We help cover these gaps with any assistance or resources that are available," says Broadway.
• Once the patients express that they would like more details on what to expect from a financial standpoint, staff members escort the patients to an available financial counselor.
Broadway says that obtaining accurate, verified data for all patient demographics is one way to prevent lost revenue.
"We are then able to seamlessly determine the eligibility and benefits of a payer and establish what the anticipated financial requirements of the patient will be," she says.
Each patient must be financially cleared for services performed in a non-emergent, elective environment. "Performing this service ahead of the appointment date reduces the number of no-shows. It allows the cancellations to be filled ahead of time," says Broadway.
Patient access employees recently met with a woman who had a limited benefit plan and whose husband's job was reduced from a full-time to a part-time position. "They lost the benefits associated with his full-time employment. The wife exhausted all their COBRA benefits," says Broadway.
The patient began coming for services and soon realized that she was paying too much money for too little coverage. Staff referred her and her husband for qualification under a state-assisted HIPAA pool coverage plan.
"She has to pay a little more each month for the premium," says Broadway. "But she has comprehensive coverage for herself and her husband with much less out-of-pocket and much more peace of mind."
Simple changes for service that 'wows'
After a patient is registered, he or she always has someplace else to go. Do patient access staff members simply give some vague directions, or do they come out from behind the desk to help the patient? At The University of Tennessee Medical Center in Knoxville, registrars make a point of personally escorting many patients for testing.
"Some testing areas are close to check-in," says patient access manager Tammy Mendenhall. "We walk those patients to the lobby and direct them down the correct hall or elevator,"
This task takes only a minute or two, but it makes a big impression on patients. "Customer service surveys often contain comments about how registrar showed them exactly what elevator to take or walked them to the testing area," Mendenhall says. Here are other simple ways to improve service:
• Avoid "sideline" conversations while registering patients.
Hearing registrars talking to one another instead of the patient can make anxious, nervous patients feel as if they're not the focus.
"It's the responsibility of registrars to help the patient feel at ease," says Mendenhall. "Participating in sideline conversations takes the focus off the patient."
• Ask marketing experts to "shadow" patient access staff.
At the University of Tennessee Medical Center, the hospital's vice president of marketing and planning "shadowed" patient access staff, with the goal of improving service.
"She provided feedback on the consistency of team members introducing themselves, using closing scripts, and escorting patients to testing areas," Mendenhall says. "These are all simple steps that will move service from good to excellent!"
• Staff members no longer ask patients, "What are you here for today?"
"This is a question the registrars had grown into asking patients," says Mendenhall. "Patients would often answer by giving their symptoms, which can be embarrassing in the lobby area."
In most cases, the registrar already knew what the patient was coming for and was only confirming this information, but patients didn't realize that the registrar knew.
"Some patients were concerned, because they felt if we were asking then we didn't know anything about their test," says Mendenhall. Registrars now state the test or procedure, such, "I see you are scheduled for a mammogram." "Registrars should already know what scheduled patients are here for," she says. Each registrar closes the patient's registration by saying, "I have all your paperwork ready. Let me walk you to ".
• Act on patient suggestions.
When a patient at Mercy Medical Center in Oshkosh, WI, asked that a park bench be positioned near the hospital's chapel entrance so family could have somewhere to sit and rest, it was done almost immediately.
The patient's request had been submitted to one of the suggestion boxes that patient access departments keep at each point of entrance. Pads of paper are near the boxes, with a sign stating, "Your voice is important to us."
"We review each suggestion and address every one of them somehow," says Connie Campbell, director of patient access. "We have implemented many changes based on this feedback."
A more challenging request involved questions about out-of-pocket costs on medications when patients stayed overnight in a bed. "We implemented a letter to explain Medicare's definition of an outpatient, which now includes some patients who might be staying overnight," says Campbell.
• Connie Campbell, Director of Patient Access, Mercy Medical Center, Oshkosh, WI. Phone: (920) 223-1874. Email: firstname.lastname@example.org.
• Tammy Mendenhall, Patient Access Manager, The University of Tennessee Medical Center, Knoxville. Phone: (865) 305-6554. Email: email@example.com.
• Elizabeth H. Broadway, CHAM, Director, Patient Access and Business Services, Ochsner Health Systems Baton Rouge (LA) Region. Phone: (225) 761-5880. Fax: (504) 842-0806. Email: firstname.lastname@example.org.
• Rebecca Holman, CHAM, Patient Access Manager, Mercy Hospital, Springfield, MO. Phone: (417) 820-5342. Fax: (417) 820-3465. Email: Rebecca.Holman@Mercy.net.
• Jen Nichols, Senior Director Revenue Cycle Operations, Kaleida Health, Buffalo, NY. Phone: (716) 859-8382. Fax: (716) 859-8664. Email: email@example.com.