Gain a clear understanding of the change and when it will take effect.
Hospitals and health systems should develop a plan to implement whenever health plans make coverage changes. That helps revenue cycle leaders understand how changes are affecting provider organizations and their patients—and it may provide information that will help with health plan negotiations. That’s the word from Sandra Wolfskill, HFMA’s director of healthcare financial policy, Revenue Cycle MAP. She suggests this six-step protocol whenever a potentially concerning coverage change is announced.
Get the facts. Obtain the health plan’s provider bulletin so you can see the details of changes in writing.
Meet with health plans. Schedule meetings with health plan representatives to discuss information in their bulletins. This allows hospital leaders to verify that they understand coverage change details and when they are happening.
Help educate patients affected by health plan changes. Ask health plans to provide copies of the materials being used to educate their members about coverage changes. “Then we know what they have told their subscribers, who are our patients,” Wolfskill says. “That helps us communicate the same information.” Provide staff with scripts to use with patients who are affected by changes.
Determine what you need to do in response to health plan changes. Many patients will continue to seek services as they have in the past, unaware of how coverage changes affect them. Decide what your organization will do when that happens and train staff accordingly. “For example, if the health plan says it’s not going to pay for something if it’s provided in a specific setting, what do you need to do when that patient presents for that service and appears to need it?” Wolfskill says. Issues to consider include:
- Educate physicians on documentation that is affected by health plan changes.
- Ensure staff have appropriate scripting and understanding in place to explain health plan changes to patients.
Monitor claims for compliance with health plan changes. Create new claim edits that identify claims affected by coverage changes. “Intercept those claims so that they can be reviewed internally for compliance with new health plan policies,” she says.
Track denials. Set up tracking codes that identify denials that occur under new health plan policies. Review those denials to determine bases for appeals. Then analyze those denials over time to see patterns that could inform solutions. Why was the claim denied and could anything have been done to prevent it?
If claims are denied, communicate with patients, who may not have understood how their health plan’s change would affect their out-of-pocket responsibilities. “Ask the patient to go back to the health plan and help get the claim issues resolved,” Wolfskill says.
Lola Butcher is a freelance writer and editor based in Missouri.
Interviewed for this article:
Sandra Wolfskill, FHFMA, is director of healthcare financial policy, Revenue Cycle MAP, HFMA, Westchester, Ill.