Patient access managers must train their representatives to adapt to the new Advance Beneficiary Notice (ABN) of Noncoverage, which CMS released March 3 and that will be mandatory for facilities to use by September 1.

The focus of the training should be on the new requirement for access staff members to provide a cost estimate of the service to the patient, says Yvonne Focke, RN, BSN, MBA, regional director of revenue cycle management at Mercy Health Partners in Cincinnati.

In an age of competitive healthcare in which patients shop more than they ever have, some access managers may have already addressed cost estimates; now, they all have to address it.

“That’s a huge change,” Focke says. “It was always kind of a wish list [item] before.”

Cost estimates the biggest change

The key for access managers is to start simple, says Focke.

“Have an agreement with your chargemaster people and with your patient financial services and revenue cycle people and say you want a list [of prices] that you can work from,” Focke says. “From the list, then the training begins.”

The ideal approach is to use medical necessity screening software that also produces the ABN document “as a byproduct of the actual screening,” says Sandra J. Wolfskill, FHFMA, president of Wolfskill & Associates, Inc., in Chardon, OH.

Managers who do not have that type of tool need to create a data file that contains the CPT codes and that matches those codes to the tests and costs for services provided at the hospital. An Excel or Access database can be used, Wolfskill says.

“However, managers must remember that any database or set of cheat sheets developed are only accurate as long as the chargemaster does not change,” she says. “Updating these types of stand-alone lists is an important issue, and failure to keep the lists current will result in patient complaints when the bill received does not match the amount listed on the actual ABN document.”

Training: CPT codes, scripting

Scripting may be the best training method regarding cost estimate, Focke says. Access managers can provide examples of what a patient may ask regarding the cost of a service, and access representatives can practice their answers.

Above all, access managers must ask themselves, “Are we prepared to do a cost estimate?”

Focke suggests adding in cost estimates manually during training. Later, an automated system of cost estimates would be beneficial to a facility and its access manager and representatives.

In terms of training, Wolfskill says access managers must:

Hone medical necessity screening skills so that frontline staff members understand CPT codes and how to identify the related charges for those codes.

What is the process in your organization for resolving the coding of an order that does not contain CPT codes? Do front-line staff members have immediate access to trained coders who can assist them?

Review the new form and have staff members practice completing the form. You may discover that staff members have developed shortcuts while completing the old form. Eliminate any bad habits now during the training process. The form must be completed, which means all lines must contain the appropriate information.

Develop scripts to practice explaining to patients why the form is needed and how you arrived at the cost information. Leaving dialogue with patients to chance is risky; doing so may result in patient complaints.

Patients need to understand that although their physician may have ordered a particular test, their insurance (e.g., Medicare) may not pay for this service. Additional components of the dialogue include discussing the estimated cost and the various payment options available.

Address estimates with patients; refer calls to the actual department

But what if a price is not on an access representative’s “cheat sheet”?

“If a facility starts with pricing for the most common procedures, they need to decide how they are going to handle estimates for procedures that are not available or are not on their cheat sheet,” says Steven G. Orvis, MPH, director of revenue cycle services at Sinaiko Healthcare Consulting in Los Angeles. “Will there be someone from CDM who will be available for this estimate if a patient is standing at the front desk?”

Too often, managers see patients who are unhappy with the bill because it was not what they expected. Orvis says the cost estimate process is not an exact science.

“I have seen many cases where patients were very upset because the original estimate was not the same as the actual charges [even if they were relatively close],” says Orvis. “The facility needs to know what to say to the patient both when the estimate is given and when the patient calls customer service complaining that the charges were not what they expected.”

David Mier, vice president/chief revenue officer at Children’s Hospital in Omaha, NE, says his facility provides a list of procedures along with their average charges as a basis for the estimate to the patient, and a form describing scripting and its methodology to the representative so that he or she may further help clarify the situation to the patient. The patient should then understand that it is an average charge that could vary based on the actual procedure.

“Because the charges are generated at the CDM level, not at the procedure level, it is almost impossible to provide an accurate cost for the procedure unless package or case-rate pricing is used,” Mier says.

So what happens if a patient complains about a price that was not within a reasonable range of the estimate the facility provided?

“In our case, I would basically reiterate that our estimates are based only on average charges for the procedure, and what they were provided was exactly that,” Mier says. “If the charges are significantly higher than the estimate, I would have our nurse auditor review the account and see if there were complications, etc., that resulted in the above-average charge.”

Wolfskill says an access manager’s organization must have a policy in place for how to deal with these situations.

“Given the difference between cost and charge built into many chargemasters, you may want to consider allowing customer service representatives to immediately adjust the charges down to the amount quoted on the ABN form,” Wolfskill says. “Alternatively, use a system edit to force a screening of the bill versus the ABN before release to the patient. Teaching staff to apologize for the variance and correct the situation promptly is the best way to handle these types of situations.”

T.T. “Mitch” Mitchell of T.T. Mitchell Consulting, Inc., in Syracuse, NY, says he would refer patient complaints to the actual department that did the procedure so it can review the charges.

“The first thought might be to route it to the billing department, but I always sent people to the source,” Mitchell says. “Some facilities might not want that to be policy, but that would be the process in reviewing what actually happened that caused a change in the procedure.”

Forming the pricing list

Ideally, facilities should have an automated process to help determine coverage details and pricing, says Mitchell. If it’s not automated, a list of the top 20 tests that may not be covered and their prices would be sufficient—“maybe even only the top 10, since most physicians seem to get into a pattern of requesting the same lab tests over and over,” he says.

“This is way more significant than scripting,” Mitchell adds, “because access staff should have already had somewhat of a script in place for when they had to give an ABN to a patient.”

In a pricing list, each item would be at a flat fee, but if a hospital has a discount rate for self-pay patients, it could apply that at the time. “With a list, there’s no big retraining or much change of a script,” says Mitchell.

Mier says his facility generates a list of surgical procedures for the previous 12-month period and uses that as the basis for calculating average charges for each procedure. This average charge approach accounts for fluctuations that might arise due to patient complications.

Ultimately, changes in the ABN signify that the access role is critical to a facility’s financial well-being, as revenue cycle managers, such as Focke, have observed. The performance at the front end is becoming increasingly important, and thus managers must hire representatives who can do more than enter data.

“I personally see a million things coming across those access people,” Focke says. “This is not something that’s alarmingly difficult. However, it’s one more thing to me that indicates that more activity is moving to the front end. The front end is no longer just a clerk. These people need to have more educated billing savvy. It points to the need for higher-level employees on the front end.”