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Empowering patients as financial advocates

By Mary Shaub, M.H.S.

Patients, who can be viewed as the highly valued commodity in health care, are the focal point for insurance companies and physicians. Patients are valued by the insurance industry because these customers are the foundation of their insurance premiums through which this industry derives its profit. In the year ending 2001, Aetna reported having total health care revenue of $25.2 billion covering 17.2 million patients. Independence Blue Cross reported on its year 2000 annual report, $7 billion in gross underwriting revenue covering 4.4 million patients with gross reserves totaling $661 million at year end.

In the same vein, patients drive the revenue of your practice by their need for health care. Until the emergence of managed care, whose primary focus is the elimination of the skyrocketing cost of health care, the patient’s loyalty had undoubtedly been with their primary caregiver, the physician.

The insurance industry, while earning billions of dollars in premiums, has launched a successful campaign to reeducate patients into believing that the physician has caused this catastrophe. For example, a recent Philadelphia Inquirer article entitled, “Medicare mistakenly pays out $12.1 billion” stated that auditors believed this error was caused by physicians unnecessarily hospitalizing patients. With this type of media coverage gaining patients’ attention and confidence, the communicated source of the problem is clearly not the insurer.

What follows is a proven methodology that can reverse this trend in thinking while providing your practice with additional resources for collecting insurance monies. By working with your patients through education and supportive customer service, and by communicating financial expectations and outcomes, your practice can redirect their loyalty, strengthen the patient-doctor relationship and create additional financial advocates for your practice.

The first step is to educate your patients on insurance issues ranging from coverage components through reimbursement requirements starting with their first visit. Educational materials, whether on paper or via computerized presentation, should be easy to understand and follow. A website that can assist in the development of easy to understand patient friendly literature, is www.plainlanguage.gov.

There should be three major sections: information about insurance types, methods or tools to record and track their financial information and your practice’s financial policies. The insurance material should cover topics associated with traditional indemnity insurance, the managed care industry’s HMO, PPO and Point of Service products, Medicare and Medicaid. If your practice has a majority of worker compensation cases or automobile cases, these insurance plans should be addressed as well. Include in this section a glossary of common terminology, which is imperative to completely understand insurance. The second part of the package will contain information for the patient to understand the financial components associated with their visit, such as referrals, authorizations, co-pays, deductibles, coinsurances, coordination of benefits and non-covered services. It should provide them with a method to track all relevant financial information associated with their visit. The last part of the packet should include information about your practice’s financial responsibility policy. Inherent components of this section will include the insurance verification or registration form; the advance beneficiary notice; consent to release information; financial contacts in the practice; philosophy of working with the patient in the resolution of claims and the financial policy regarding patient balances, including the frequency of billing, payment plans and referral to collection.

The second step is to provide the patient with a high level of customer service. Insuring that your office staff creates, from the first telephone call through the completion of the visit and resolution of the claim, an environment in which the patient feels valued engenders a feeling of empowerment and camaraderie. So often, the nonverbal cues provided by tone of voice and body language initiates the patient to the quality of care provided by your practice. A website which has useful tools to assess customer service skills and techniques for communicating your commitment and sincerity to the patient is www.susanbaker.com .

Office staff should be trained to understand the insurance issues faced by patients. Understanding the questions posed by patients and guiding them through the continually evolving health care reimbursement maze will establish your practice as their advocate and ally. It will encourage patients to view your staff, and not the insurance industry, as their resource for reliable insurance information. A quick reference for training staff to understand the issues faced by patients in making insurance choices is Cliffnotes, Understanding Health Insurance by Darlene Brill.

The third and final step is communicating financial outcomes and expectations to the patient. Since the patient has been provided with your practice’s financial policies, your encounter form or charge ticket provided at check out should include all current and past unresolved financial information. This will communicate the collaborative financial effort between your office and the patient. It will also give them a reference tool if their assistance is needed as your financial advocate with the insurance company. Continuing to build on the “partnership message” between your practice and the patient, the patients are further empowered as educated consumers who are financially accountable for the cost of their medical care.

If the insurance company refuses to process the claim or the patient has not responded to their request for additional information, call the patient and provide them with what they can do to assist in the final resolution of the claim. Patients will expect to receive this call, since your practice’s financial policy informed them of your perspective in collecting insurance money. It is helpful to provide staff with a variety of insurance scripts to instruct the patient how to best advocate to the insurance company. The insurance representative’s name or department contact information is an imperative ingredient of these scripts. Many insurance companies have websites where providers and members can look for information. The goal is to equip a well-educated patient with all the necessary information to be an effective financial advocate. As such, you have extended your reimbursement capacity without additional overhead, while simultaneously strengthening a partnership between you and your patient.

In our health care marketplace, the physician must utilize all possible approaches toward strengthening their financial systems. This method, when used effectively, creates a win-win situation for the patient and the physician. Through this three-step approach of patient education, customer service and communication, your practice will empower an unlimited source of financial advocates communicating that your success is determined by putting the patient first!

Mary Shaub, M.H.S., is president of Shaub Medical Consulting, based in Philadelphia, Pa.

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