Payer changes call for new access skills

Otherwise, denials will result

Patient access staff members at University of California — Los Angeles Health System are using several newly implemented automated tools to keep up with payer requirements.

"It's becoming even more important to verify eligibility and benefits," says Bernadette Lodge-Lemon, director of revenue cycle. Here are some recent changes:

• More often, health plans have different benefit levels within employer groups.

This change might mean the patient has different benefits than what staff members see when claims are processed. "Instead of doing this on a manual basis, we are looking for tools to do things in mass quantities," says Lodge-Lemon.

• Payers have more numerous requirements.

Members of the patient access staff use an eligibility tool that gives reminders if registration data is incomplete. "It's hard for staff to remember so many different rules," says Helen Contreraz, director of patient access services. "We have to rely a lot more on electronic tools for the staff, including building in some intuitive business logic."

• Many payers have switched to 24/7 notification policies.

This change means that staff members are required to notify the payer of a patient's admission even after hours or on weekends and holidays, when staffing is sparsest, says Contreraz. Staff might be unsure who needs to be notified of the admission, or who the contracted facility is if the hospital doesn't have a payer relationship with the insurer.

"There are fewer resources to reach out to if there are questions," she says. "If there is a problem, it may not get to auditing until the first business day, and then you are too late. The days when registration was 'greet the patient and smile' are long gone. Staff have to interpret the electronic responses from payers, to be sure they aren't missing any critical data." Different payers return information differently, she explains, and managed care contracts vary in their requirements.

"It's no longer on automatic pilot. You really have to understand the information you are receiving back from the payers," Lodge-Lemon says. "A lot of it is judgment and knowing what to do with the information you receive."

This month: How healthcare reform will change patient access

This issue of Hospital Access Management is a special issue on healthcare reform and its impact on access management. Inside, we report on cutting-edge strategies to prevent revenue loss for your organization and the skills patient access staff need right now. We give strategies for doing more with less staffing and revamping your processes for payer requirements, insurance verification, and cross-training. Enjoy this special issue!