Patient Access

It All Starts with Patient Access

November 16, 2017 3:53 pm

Empowering patients with high deductibles helps improve your bottom line.

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Healthcare consumerism and high deductible health plans (HDHPs) are our new reality, and hospitals and health systems are going to have to be much more proactive to survive this era.

Because it all starts with patient access, these staff members now need to be more than information gatherers. They need to be patient advocates, gifted with genuine empathy and know-how—not only to guide patients through the financial experience, but also to set the stage for clean claims downstream.

By doing so, hospitals and health systems can maximize their revenue flow while improving patients’ overall experience and satisfaction.

Patients Need to Know: What They Owe

Think from patients’ perspectives for a moment. Patients feel that they are literally putting their health in their providers’ hands. They need to trust that their providers are looking out for them—both clinically and financially. They want clinical and financial transparency.

With the push for greater price transparency, many providers are choosing to publicize their rates on websites or portals for patients’ convenience. However, providers need to be careful with the information they put out there. They need to be very clear: These are just estimates that can change based on many different factors.

That’s why it’s critical for patient access staff to have direct conversations with patients. They’ll have a more precise forecast of how much patients will owe if they have a complete picture of patients, their healthcare coverage, and the care they are about to receive.

Consider Margaret. She’s a 65-year-old woman who will be undergoing full knee replacement surgery. She has orders for an MRI and knows she’ll be in the hospital for at least a few days with rehabilitative care to follow. There are a number of factors that could impact the price of this procedure, ranging from whether she’ll need a sedative during the MRI to the setting in which her rehabilitative care will take place.

A general estimate could be off by thousands of dollars, which means her out-of-pocket expenses could be considerably more than what she’s planning to pay. By contrast, a patient access team equipped with specific orders from the provider (e.g., titanium or steel implant, two- or three-day hospital stay) and Margaret’s current insurance information can walk through these factors with her and calculate a more accurate estimate.

Patients Need to Know: How They’re Going to Pay for It

The cost of healthcare—and how to pay for it—is the financial concern most often cited by Americans, according to a recent Gallup poll. With HDHPs and out-of-pocket expenses in general on the rise and likely not going anywhere, patient access staff must be able to help patients figure out how they can cover their costs.

The first step in this process is to verify patients’ benefits and formulate accurate estimates. From there, patient access staff can help patients figure out if they can afford the out-of-pocket costs. If not, staff can navigate them toward payment plans or financial counselors.

They should also consider any and all possible ways to offset patients’ expenses by looking for alternative payment sources. For instance, could these expenses be covered by home-owners or auto insurance? Does the patient qualify for Medicaid? Is the patient below the federal poverty level and qualified to receive for financial assistance or charitable funds?

By showing empathy and guiding them through the financial experience, patient access staff can empower patients and improve their satisfaction levels. In turn, this sets patients on successful paths to paying their bills and protecting the organization’s revenue flow.

Clean Claims Begin at Registration

Payers in this equation—from commercial health plans to Medicare and/or Medicaid—rely on healthcare organizations to do two things:

  • Provide clear and accurate information about patients and physicians’ orders
  • Follow specific procedures for submitting claims

Any incorrect assumptions, oversights, or misstep could result in denials or underpayments, which underscores the importance of quality assurance (QA) at registration. If patient access staff neglect to verify patients’ eligibility or to obtain preauthorizations, claims likely will be denied.

Let’s revisit Margaret’s scenario for a moment. What if her doctor prefers to use titanium knee replacements, but her insurance only covers steel implants unless certain conditions are met? If the hospital fails to verify both eligibility and pre-authorization requirements prior to her surgery, the claim may be denied.

Although the denial could possibly be overturned, the hospital will still lose revenue due to the expense of the appeals process, as well as a potential difference in payment. Moreover, denied claims can cause a great deal of frustration and added expense for patients, which could taint their entire experience.

This is why capturing the right data from patients and making corrections in real time are both key components of QA. To do so effectively, patient access staff need to know how to draw very personal information from patients at an often stressful and worrisome time. After all, nobody wants to be in the hospital. So, patient access staff should be armed with effective tools to prompt and gather the right information in real time even as they drape the patient in kindness.

The Right Combination Will Optimize Your Revenue Cycle

Patient access teams should have one goal when it comes to patients’ financial experience: Make it the least disruptive as possible. This requires empathy and industry expertise, but it also requires the right tools.

Key technology—including estimation, claims analysis, population health, and payment performance tools—can help hospitals and health systems accomplish the following:

Collect and assess relevant information. There is no shortage of data in the digital age, but having the right data can make a huge difference in how claims are processed. Using technology, patient access staff can follow workflow best practices and collect accurate information to help patients on both the clinical and financial sides.

Triage patients based on financial needs and options. Technology can be used in a number of ways to help assess patients’ financial needs and predict behaviors. For example, population health data and payment history can be used to determine patients’ ability and propensity to pay. Staff can then triage patients into payment plans or to financial counselors to maximize patient payments and patient experiences.

Automate the revenue cycle. Automating parts of the revenue cycle can ensure it is streamlined and promotes clean claims. For instance, obtaining eligibility verification or preauthorizations can be built into workflows so these steps are not inadvertently overlooked.

In this new era of HDHPs and consumerism, healthcare organizations must optimize their revenue cycles by maximizing payments from all payers. By using the right combination of empathy, industry expertise and technology, they can empower patients financially as well as clinically, and improve the entire healthcare experience.

Eric Krepfle is associate vice president, Change Healthcare.


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