This is Part II of a three-part series on maximizing your pre-admissions through effective preregistration and scheduling, prior authorization/pre-certification, and post-contact follow-up. You can read Part I here. Part III can be found here.
Once you have established the foundation for an effective pre-admissions process (see Part I), you are ready to implement the three legs to the pre-admission’s stool: scheduling, prior-authorization/pre-certification, and post-contact follow-up. This article deals with establishing the first two, and we’ll examine post-contact follow-up in Part III.
Scheduling requires highly qualified teams that understand that they are integral to the financial success of the facility. Scheduling errors in many facilities can represent 25 percent of the denials from insurance. Mistakes are as simple as name changes, inappropriate address, wrong social security information, incorrect numbers for insurance, incorrect insurance…you get the point!
- Your scheduler in the clinic must have training that allows the patient to know what the expectations are when they come for their appointment. The scheduler for a procedure in the hospital should perform this job expediently and explain to the patient what the expectations are once the procedure is scheduled.
- Both of the aforementioned scenarios must consider the fiscal impact to both the facility and the patient. Hence, discussion of fiscal responsibility is necessary at this level of patient contact.
- Consider that in the clinic you must explain to the patient the requirement to bring their insurance card, be prepared to pay their co-pay and in the truest sense of success explain to the patient that if they have prior balances, payment of these will also be expected at time of service as agreed upon by the financial counselor.
- In the hospital environment the responsibility is to share with the patient that you will schedule the procedure and insure they understand that they will receive a call from a financial counselor to explain their coverage, etc.
Prior Authorization/Pre-Certification Process
Let’s examine Prior Auth/Pre-Cert from a different perspective. We are going to examine how we accomplish this task by gaining information that is essential to the Pre-admission/Point-of-Service process.
It is amazing how many facilities believe that this task is complete, but find out it is not. This action is the stabilizing foundation verifying the patient has coverage for the services. Many times we find that specific procedures require different handling when the insurance company limits or determines that the service must be reviewed to meet the contract’s requirements.
Many facilities that complete this process do not fully comprehend that the process is not only limited to specific coverage for the services the patient receives. This process is needed for the facility to be fiscally responsible in a number of different ways. This process must include:
- At the clinic level, the process allows for verification that the physician’s services are covered and hence paid.
- At the hospital level, the process allows for verification that the hospital services are paid. Note: The hospital verification team should not automatically assume physician service verification. The staff needs to acknowledge and request from the insurance company if physician authorization for services are necessary.
- Both clinic and hospital verification must include an additional step other than reciting the services that will be completed. The staff needs to discuss with the insurance company the patient’s benefit package and the actual out-of-pocket costs that the patient must pay.
- Once we identify out-of-pocket costs, you now have an opportunity to share this information with your financial counselors. This enables a phone call to the patient to discuss the “estimate” of Self Pay the patient will need to pay.
Please review the above with your staff. Appropriate policies must become the cornerstone of this critical component of the process. Lack of preparation and documentation can easily result in a denial from insurance. Make sure your staff is fully trained to understand all aspects of this specific process.
Continue to Part III here.
Chuck Seviour is vice president of revenue cycle for Array Services Group. Chuck has over 40 years of healthcare industry experience ranging from director of business office operations for a large health system to consulting with more than 150 hospitals as a healthcare consultant for a major accounting firm.