The patient’s experience begins the moment they choose or are referred to UTMB for their healthcare needs. Their experience includes their entire journey from setting the appointment, seeing our providers, receiving treatment, follow up appointments, etc. Every step of their journey is important. The financial responsibility piece of the patient experience can be especially stressful for many patients. Their insurance plan is like a contract that will not only provide information about covered benefits but also the patient’s financial liability. It becomes our responsibility to help the patient understand their financial responsibility and make a reasonable effort to collect their part. Waiving the patient’s co-pay, co-insurance, or deductibles can be considered a violation of our contract with the insurance plan.
Prior Authorization - Insurance plans require prior authorization for certain services and procedures. It is our responsibility to verify if a service or procedure requires a prior authorization and inform the patient of their financial responsibility. It is critical that all planned procedures are coded appropriately when ordered or scheduled, as the codes drive authorization requirements AND patient liability. If we fail to obtain the required authorization, the plan will not reimburse us and many times the patient is held harmless for their portion. In effect, if we do not do it right, we are sacrificing revenue.
Re-Authorization – It is not unusual to preauthorize a procedure then when the surgeon performs the surgery, the procedure(s) change and/or additional procedures are added. For office procedures, it is essential that the surgeon updates the procedure and diagnosis code(s) and informs the clinic manager or appropriate staff so the correct or additional procedure code(s) can be authorized. For procedural areas, the surgeon or proceduralist will update the procedure and diagnosis code(s) in the Post-Op MD Navigator. Here is the workflow and a short instructional video for the Post Op MD Navigator and the 3M system to choose the appropriate procedure and diagnosis code(s) for the procedure(s) performed. Without this re-authorization, the insurance plan will not reimburse and the patient will, most likely, not be held financially responsible for the procedure. We have 24 hours to obtain a reauthorization.
How are we doing on collecting the patient’s portion?
As of February, we are collecting the patient’s responsibility for procedures at a rate of 85%. We continue to optimize the pre-service collection processes to increase this percentage.
 | Revenue Cycle Financial Clearance is working in conjunction with Coding Education to bring you information to manage the patient experience for all patients at UTMB. We invite you to contact us to schedule large group, small group, or 1:1 training. We are dedicated to the education and success of all UTMB providers. Please contact the Revenue Cycle Coding Education Team to ask questions or schedule a meeting. We are here to help! Email the Coding Education Team. |