The Patient, The Clinicians, The Payer, And The Hospital Encounter
By Ronald Hirsch, MD, FACP, CHCQM
While efforts continue to be made to improve the quality and efficiency of care provided to patients in a hospital (this includes many of the qualifying payment programs being tested by governmental and private payers), the industry cannot overlook how patients view their financial obligations and how their financial situation impacts their course of care.
Increased patient liability due to high deductible health plans and higher copayments/coinsurance amounts have made patients question whether they should even seek medical care or defer until their condition worsens. When they do seek care, they need to decide if they should schedule an appointment in the office, visit an urgent care facility, go to an emergency department or even dial 911. That decision has significant financial implications if the chosen provider is out of network or if the payer did not require emergency department care or need an ambulance to be called. Often, this leads to a claim being denied in full.
Once a patient enters a hospital, registration creates a lasting impression that will influence the rest of the experience. Patients must navigate the registration gauntlet—which includes being asked multiple questions, receiving countless forms to read, confirm and sign, with a sense of urgency and frustration—all while thinking there must be a better way.
For patients entering the emergency department, Emergency Medical Treatment and Active Labor Act (EMTALA) regulations apply, but it’s important to note that “a hospital may follow a reasonable registration process, including asking for insurance information, as long as it does not delay screening and treatment.” Obtaining accurate demographics and insurance information is extremely important and will affect future steps in the patient’s care journey while in the hospital and after discharge. Knowing the proper payer source allows the care team to provide the best care, at the most reasonable costs allowed by insurance.
Many hospitals have adopted a “payer agnostic” policy, where the care provided is not affected by the payer. While this may seem favorable, it is not a patient-centric policy. For example, if a patient presents a fracture, is treated and then referred to an orthopedist for outpatient follow up, the patient would then expect to be referred to an orthopedist who is part of their insurance network. Many times, the patient goes home, calls the orthopedist office and learns that they do not accept his/her insurance and the patient must pay out of pocket. Patients are then forced to contact their insurance companies and look for an in-network orthopedist, which creates a delay in care as well as patient frustration. Even if the emergency department care was great, the negative experience with follow up care will negatively influence overall perception.
For patients who require hospital care, accurate payer determination is key and makes a significant impact on patient satisfaction. Many payers require notification of hospital admission within a specific time frame. If the wrong payer is listed, that delay in notification could lead to a denial of payment, potentially exposing the patient to higher out-of-pocket costs. If the hospital is out-of-network, arrangements to arrange transfer should happen expeditiously, with the patient’s consent, in order to avoid denial of payment or exposing the patient to increased financial liability.
For hospitals to participate in the Medicare and Medicaid programs, a discharge plan must be developed for most patients. That discharge plan is often dependent on the payer, as many requiring pre-authorization for transfer to a post-acute setting such as a skilled nursing facility or specific home health agencies. Confusion can lead to delays in obtaining necessary care, as well as unnecessary work by the case management staff, ultimately prolonging the hospital stay.
The increased number of Medicare-eligible patients who are enrolling with Medicare Advantage plans also requires careful attention to patient registration and insurance verification. Many seniors with Medicare Advantage continue to think they are “covered by Medicare” and don’t understand that Medicare Advantage part C plan has replaced their part A and B plan. Registering a Medicare Advantage plan patient as if they are covered by traditional Medicare leads to lack of authorization for the admission, improper referrals for post-acute care, and can create significant delays in progressing the patient through the continuum of care. Patients view these delays as deficiencies with the hospital administrative functions, which leads to a negative experience.
Proper and thorough patient registration and insurance verification benefits both the patient and hospital during hospital stays and beyond. Ensuring that these processes are completed accurately, efficiently and in a patient-friendly way is critical. Many revenue cycle partners are beginning to use technologies such as automation and machine learning to share information across the various touch points of a health system’s revenue cycle to enhance patient satisfaction. Having these capabilities will pay dividends many times over in improving the patient experience, staff efficiency and payment accuracy.
About The Author
Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at R1 RCM. To learn more about R1 RCM, click here.