CHAA Examination Preparation Encounter - Session III Pages University of Mississippi Medical Center

What to Expect… This module covers various aspects of Patient Access knowledge found in pages of the ENCOUNTER section of the 2010 CHAA Study Guide. A quiz at the end will measure your understanding of the content covered.

Increasing Cost of Healthcare Healthcare costs escalated 5.5 times the general rate of inflation between 1999 and Also, the percentage of employers offering health coverage fell 9% between 2000 and Due to the rising cost of healthcare, more insurers and employers are: – shifting a greater share of the healthcare costs to consumers. As a result, the number of self pay patients INCREASED from 5% in 2000 to 10% in 2004.

Self Pay & Bad Debt The growth in self-pay populations has resulted in an increase in BAD DEBT. Most hospitals collect between 2% and 8% of charges to uninsured patients. With overall margins averaging only 3% to 5%, hospitals cannot afford to ignore self- pay accounts. Self-Pay patients could exceed 30% of hospital revenues by 2012!!!

Collecting Patient Liability Due to the fact that consumers are becoming more responsible for their healthcare cost and that bad debt due to self-pay patients is increasing, POINT OF SERVICE COLLECTIONS are becoming more important to a hospital’s bottom line.

Point of Service Collections – When? Best hospital practices begin collecting money from patients, At the TIME OF SCHEDULING or REGISTRATION because there is a PSYCHOLOGICAL ADVANTAGE of collecting during the early stage of the revenue cycle.

Benefits of Up-Front Collections Beginning the collection process during the first encounter with the patient allows us to: Assess the patient’s insurance coverage and other financial resources Screen all patients to determine ability to pay vs. those requiring assistance Present the patient with an estimated itemized bill of his/her financial obligations

Benefits of Up-Front Collections Secure payment from those who can pay at point-of-service and arrange for payment terms for balance owed based on the hospital’s collection policies. Find payment sources for those who cannot afford care (identify potential federal, state, local, private, and charity funding sources) and automate the application process.

The Five Major Control Points Many healthcare providers mistakenly assume the collection process begins with: – COLLECTION FOLLOW UP. Doing so IGNORES FOUR OF THE FIVE MAJOR CONTROL POINTS.

The Five Major Control Points During the first four control points, your dealing with: –a PATIENT, not a DEBTOR. Research has shown that PATIENTS are more likely to pay their liability than a DEBTOR.

Calculating Patient Liability It’s crucial to understand the following definitions to accurately calculate patient liability. Deductible – a portion of the covered expenses that insured must pay per benefit period before benefits are paid by the insurance plan. Maximum Out-of-Pocket – the most money an insured can be expected to pay for covered expenses per benefit period.

Previous Balance? In addition to calculating balance for the current visit, Patient Access Employees should REVIEW PREVIOUS BALANCES to determine if the patient has any liability from previous services. If they do, the balance SHOULD BE REQUESTED during the process of collecting the current estimate.

Collecting Patient Liability Many facilities provide a “Patient Liability Letter” to the patient/guarantor communicating the amount due for this visit and any previous balances if necessary. Accepting Emergency Room co-payments can only be collected once the patient is: –Screened and Stabilized –According to EMTALA guidelines

Collecting Patient Liability – Medicare Part A The Medicare Part A deductible is due at the start of each new “SPELL OF ILLNESS.” The SPELL OF ILLNESS is defined as being out of an acute or long term acute care facility for more than – 60 CONSECUTIVE days. –A daily co-insurance amount is due from the patient for days of an inpatient stay –A daily co-insurance is also due when patient chooses to use their LIFETIME RESERVE DAYS, days –Patient must SIGN A WAIVER waiver to use their LTR days.

Collecting Patient Liability – Medicare Part B The Medicare Part B deductible is due at the beginning of the calendar year. –It is usually met with the first doctor’s office visit. –Afterwards, patients usually owe a 20% co- payment for most outpatient procedures.

Billing Problems For most hospitals, the #1 reason for claims being rejected or denied is: INACCURATE DATA ENTERED DURING REGISTRATION Therefore, patient access staff must focus on getting the CRITICAL DATA ELEMENTS (CDEs) correct when collecting information from the patient

Critical Data Elements The most common CDE mistakes include: –Patient name on claim not matching patient name on file with payer –Incorrect or missing Member ID –Claim submitted to wrong payer (e.g. traditional Medicaid versus Medicaid HMO) –Incorrect address –Missing or incorrect phone numbers –Missing pre-cert/authorization/referral information needed in order to submit claim

The Importance of CDEs Confirming this information has been collected and is correct at the time of registration eliminates: –DOWNSTREAM issues associated with billing payers –Problems in collecting liability from patients