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With the ultimate plan of transitioning to a central business office (CBO) for its 10 hospitals, Baycare Health in Clearwater, FL, has taken on the task of standardizing the insurance masters throughout the system, says Martine Saber, CHAM, regional project manager for patient access services.
Previously a three-hospital system, Baycare merged with seven other hospitals four years ago, Saber explains, and each facility has its own insurance master. "Every one is different," she adds. "One has less than 100 insurance plan codes, and another has 2,600 plan codes."
The goal is to find the best practice — from among its own hospitals or from researching processes at other organizations — and to standardize the procedure for choosing a plan, Saber says. Eventually, she adds, the entire system will go to one billing method. "Even though we’re merged, we have separate databases," she points out. "Eventually, they will look the same, but they will remain separate."
Although patient access personnel began working on the project alone, she notes, they quickly realized the importance of including their colleagues in patient accounting and in the system’s managed care department. "At first, we were only looking at what would make it easier for us, but then we said, No, we might delete plan codes and cause chaos [with managed care contracts] or create more work for the back end,’" Saber adds. "About 60% of our business is managed care."
Baycare formed a multidisciplinary task force of 26, with representatives from all 10 hospitals, she says, and broke up into smaller groups to tackle individual projects. "The neat thing is that the [access] people on the team are actually registrars that do this every day, instead of managers or directors."
Patient access has the job of evaluating and revamping the way the insurance plans are named, while patient accounting is looking at changing the numbering conventions, Saber says. "Our first priority is to make it user-friendly for the registrar."
The largest number of errors, she notes, were due to choosing the wrong plan code — not choosing Cigna instead of Aetna, but choosing Cigna PPO (preferred provider organization) when the patient actually has Cigna HMO. The difficulty, Saber says, has been that insurance cards "don’t always tell you the product line" — whether it’s a PPO or an HMO — or that they list all the plans and "you don’t know which one to use."
Another complication: With the backlash against managed care, insurance companies keep changing the names of their plans, she adds, "taking the HMO’ and PPO’ off the card. Registrars are faced with having to remember which product is which to choose the right plan code."
Under the new system, Saber says, the name in the insurance master will be the name on the card. "It won’t say United HMO,’ it will say United Choice Plus.’" A naming convention is being created, she adds, so that all Medicare products will start with "MCR," all Medicaid plans with "MCD," workers compensation insurance plans with "WC," and so on.
The patient access team also is looking at discrepancies in the insurance masters at the various hospitals, Saber notes. "Why does one insurance master have one Cigna plan code, and another has 25 Cigna plan codes?" The new rule, she says, is "if anything is used less than 100 times in a year, get rid of it." Otherwise, the insurance master is so big that it’s too hard for registrars to identify the right plan code, Saber adds.
On the other hand, for hospitals whose insurance masters have less than 100 codes, more will be added, she explains. At those smaller hospitals, Saber says, the insurance master was simpler, but information that was automated at the larger hospitals had to be typed in. "That was extra work," she notes. "Registrars had to touch every plan code before it was billed."
At one hospital, there were only a few Blue Cross plan codes, she says, while another had more than 300 Blue Cross (BC) codes. "We said that if Hospital A can appropriately bill using a minimal number of BC plan codes, then we would go with their process," Saber adds. "But it turned out that even though Hospital A had a limited number of plan codes, its patient accounting employees were doing a lot of rework on the back end."
On the other hand, at Hospital B, the bills were going to the right place, she says, but registrars were making errors because it is difficult to choose the right plan code with so many to choose from. "We compromised," Saber adds. "We reviewed each BC plan code and deleted some from Hospital A, added some to Hospital A and used Hospital B’s billing process."
The rule has become that a procedure is kept if it "creates a little work on the back end, but decreases a lot of errors on the front end," Saber adds. If the reverse is true, the procedure goes, she says.
In addition to eliminating plan codes that are used infrequently, she explains, the team is able to get rid of others that were put in according to the employer associated with the code. For example, the insurance masters included United plan codes that all had the same address and contractual information, Saber says, "but said, Use this one for a specific employer.’"
The initial thought had been that would make the process easier for registrars, but instead it made it harder, she adds, because the system was so cumbersome. "Now we reduced those 20 plan codes down to one, no matter who the employer is."
To keep the insurance masters streamlined, Saber says, the system will run a usage report every year and throw out the superfluous codes. "We’ve promised ourselves we’ll never get to this point again." To help registrars choose the right plan code, "help comments" are being added to the insurance screens. The tip might be, for example, "With this plan code, the policy number always begins with an R,’" Saber says.
One of the missions of the patient accounting team, meanwhile, is to make sense of the numbers that are assigned to the various plans. "We never had a rhyme or reason before to how the numbering was done," she notes. To remedy that, the team may designate, for instance, that HMOs will be numbered 0-10, PPOs 10-20, and so on, Saber says. "When we checked around the country as to how people were doing it, this is what we found."
The team also is looking at differences in billing among the Baycare hospitals — why one facility, for example, uses two insurance codes where another uses one, she notes. "We find the best practice and do it that way."
One hospital had separate plan codes for Medicaid inpatients and outpatients, Saber says. "We didn’t have that at any other hospital. It had something to do with the way the managed care system was taking the [contractual information].
"It turned out this hospital could do what the other nine hospitals could," she adds. "We challenge each other that way."
[Baycare Health continues to refine its insurance masters and welcomes comments from peer organizations that have a better way of doing things, Saber says. She can be reached at (727) 462-7139 or by e-mail at email@example.com.]