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RIE creates process to combat strain from residential insurance denials

11/21/19 09:50:am

rie.jpgHaving an insurance denial can be stressful for patients, especially residential patients who are here from out of state. Unfortunately, residential care also has the highest denial rate and percentage of non-local patients.

“It just adds another level of stress to the patient and family,” Jeanette Osborn, manager of Utilization Review, says. “Can you imagine your loved one being 2,000 miles away and you find out that your insurance isn’t going to cover treatment?”

Patients have had to spend time getting documents and information together for a financial assistance application, even if they ended up not qualifying. This has an extra level of stress attached to it since once a denial happens, the patient is financially responsible for their treatment going forward. This made discharge planning extremely challenging. Jeanette was one of several members of the Rogers team who helped create a solution for this problem in a recent rapid improvement event (RIE).

After determining that some pertinent financial information was already being collected during an initial social services assessment, the RIE team created a form with more targeted questions. Jeanette likens the new process to prequalifying for a mortgage through the bank.

The goal for the new process was to have “very basic financial information within the first seven days of a resident’s admission,” says Megan Kurdi, inpatient clinical services manager, Oconomowoc. Megan, who participated in the RIE, says this information helps a financial counselor determine who is and isn’t eligible for accessing financial resources from the Foundation.

If someone would not qualify for Foundation assistance, the care team can instead use the time following a denial in a more productive way by focusing on the clinical aspect and creating the best possible discharge plan.

Already, the process has shown to be effective in several circumstances. In one case, the questions on the financial status form led to the care team becoming aware that a patient would likely lose their job and benefits soon as a result of not showing up for work. Because of this, Utilization Review was aware and could look into their qualifications for aid, and the treatment team was able to work job loss into their therapeutic care.

In another case, Holly Rahn Heim, Rogers Operating System deployment leader, says “A therapist brought up these questions and the parents did not want to disclose their financial information, but made it very evident that if there ever was an insurance denial, the parents would be willing to self-pay. If staff didn’t know this ahead of time, they would have been scrambling to have the patient unnecessarily fill out a lot of paperwork and have the financial counselor review it.”

One of the reasons why the team in the RIE was able to come up with its solution was the diverse mix of both clinical and financial experts coming together.

“In the past we would say that the denial is a financial issue and not a clinical one,” Jeanette says. “But we know that finances play a big role in a patient’s stress levels and can contribute to depression. Some patients will leave treatment because they’re afraid of taking too much time off work. So, it is also a clinical issue. We were able to break down those silos between the two because we had both clinical and financial representatives on our team.”

Jeanette says that patient financial services is also exploring technological solutions to help improve the process further with less involvement from the clinical team. In the meantime, she says that any programs interested in implementing this process can contact the Rogers Operating System.

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