Incorrect info equals incorrect estimates!
Avoid costly mistakes when telling patients what they owe
Get correct codes for diagnosis, procedure
Patients want to know the dollar amount they’re responsible for, but how can members of the patient access staff possibly give them that information without the correct patient status, procedure, and diagnosis codes?
"Procedure codes are not always easily accessed, and verbal communication can sometimes be miscommunicated or misunderstood," says Pamela Konowall, manager of health care access at Cooper University Health System in Camden, NJ.
In addition, patients are not always sure exactly what procedure is planned. "In order to calculate an accurate estimate, having complete information is of the utmost importance," says Konowall.
To ensure accurate price estimates are given, the hospital’s pre-encounter team compares patient status and scheduled procedure to the OR schedule. "Should any discrepancy be identified, the team supervisor reaches out to the physician’s office for further clarification," says Konowall.
Discrepancies in patient status are sometimes identified. A patient might have been processed as an outpatient when the correct status is inpatient, which means an authorization will be required for managed care. Other patients are processed as an inpatient but should be an outpatient, which means a precertification or referral could be required by the patient’s insurance carrier. "Failure to provide either the referral or the authorization would create a denial or have a negative impact on revenue for the hospital," says Konowall.
Coding discrepancies are sometimes flagged, which require clarification. "Inaccurate coding could have a negative impact on providing a patient with an accurate estimate," says Konowall.
Patients will want refunds
At Mercy Hospital — Springfield (MO), registrars use an automated price estimation tool to complete estimates prior to the visit, if scheduled, or at the visit for walk-in appointments.
"The most important thing we have learned is to get the estimates to patients early if at all possible," says Michael Spence, MBA, financial analyst for patient access.
Any substantial inaccuracy in an estimate is bound to be a patient dissatisfier. "The expectation of a patient coming in for healthcare is accuracy at its finest," says Spence. "That does not mean just clinical accuracy, but administrative accuracy as well."
If the estimate turns out to be too high, this situation results not only in refunds, but also some distrust. "If patients see these, they begin to want to delay payment until after billing because they don’t trust the estimate," says Spence.
In this situation, registrars explain to the patient that estimates are based on what the typical procedure will be, but in healthcare the final outcome is based upon the individual circumstance. "Also, certain amounts may change as charges flow through their insurance provider," says Spence.
If the estimate turns out to be low, on the other hand, some patients won’t pay the additional amount that is due. "We have had patients refuse to pay the difference, even though we make it clear that our estimates are just that — an estimate," says Spence. "As a result, we have seen some instances of lost revenue."
Registrars review the medical record and itemized bill, and they identify what charges were above the norm or not originally expected. "Generally, this will satisfy the patient," says Spence. "But at times, they stand strong by the original estimate."
After noticing a trend of patients beginning to "price shop" by calling several hospitals in the area to compare out-of-pocket costs, patient access leaders at Cooper University Health System gave certain employees the job of giving estimates to patients.
The hospital’s "pre-encounter team" gives estimates to insured patients several days before their scheduled appointment, and the patient accounting team gives estimates to uninsured and underinsured patients.
"Many more patients are asking for estimates for a variety of services, including infusion treatments, lab work, radiology, and surgeries," says Konowall. "This reflects a major shift in how patients are choosing their healthcare provider."
Patients are choosing hospitals not only where they have confidence in the clinical reputation of the provider, but also where they believe costs are reasonable and customary, says Konowall.
"Patients are making informed decisions as to where they choose to receive services," says Konowall. "Clearly, revenue is at stake if patients choose another provider for any reason." (See related stories on obtaining current coverage information, below, and using an automated price estimator, below right.)
For more information on giving accurate estimates to patients, contact:
• Pamela Konowall, Manager, HealthCare Access, Cooper University Health System, Camden, NJ. Phone: (856) 342-2437. Email: konowall-pamela@CooperHealth.edu.
• Terri Miles, Manager, Patient Access, Wheaton Franciscan Healthcare, Glendale, WI. Email: Terri.Miles@wfhc.org.
• Michael Spence, MBA, Financial Analyst, Patient Access, Mercy Hospital — Springfield (MO). Phone: (417) 820-9897. Fax: (417) 820-4880. Email: Michael.Spence@Mercy.Net.
Outdated information is one reason for denials
Registrars need current information
When giving price estimates to patients, do staff members have accurate information about the patient’s current coverage?
"If we are working with a patient on eligibility or benefits and are not using the latest information available, this could directly affect the patient’s out-of-pocket responsibilities," says Terri Miles, manager of patient access at Wheaton Franciscan Healthcare in Glendale, WI. Here are problems that can occur:
• Registrars could miss identifying an HMO or PPO affiliation during the preregistration process.
"This could mean that we miss timely notification of that service, which creates penalties for the patient and/or the organization," says Miles. The key to avoiding this situation is making sure that the registrar is paying close attention to the detail provided by the payer related to plan participation, she advises.
• The hospital is not a participating provider for the carrier, which results in a reduced payment from the carrier.
"For the organization, it could mean an increase in the payer allowance. For the patient, it could result in a higher out-of-pocket responsibility, due to out-of-network benefits," says Miles.
• Registrars might receive outdated information about a patient’s coverage, depending on the timing of the inquiry and the database being accessed.
"This could include termination of coverage or changes that have not yet been updated by the carrier, such as a benefit change the group may have had, which would alter the patient responsibility for that service," she says.
For example, coverage termination or benefit changes could occur at the start of a new month. "Employment could have terminated during the previous month," says Miles. "Or a benefit change could have been implemented, directly affecting the patient’s out-of-pocket responsibilities."
Miles says this situation probably can’t be avoided fully, unless a call is made directly to the employer to verify their eligibility information for the upcoming date of service.
To be sure you have the most current information on the patient’s coverage, Miles says to do the following:
- Gather detailed information from the patient.
- Use an eligibility application to verify information.
- When in doubt, assist the patient in contacting the payer.
"That is actually who they have the contract with and who can also provide them the latest, most accurate information," says Miles. "When it is a group health plan, we advise patients to check with their human resource department for policy details."