How to Navigate Complex Healthcare Insurance Policies

Complex insurance situations need extra care to ensure patient satisfaction and reimbursements. You must understand certain circumstances like:

• Coordination of benefits
• COBRA
• Special enrollment periods
• Other types of insurance

Understanding these situations streamlines the billing and claims processes and maximizes reimbursements. 

Below are seven common tricky insurance situations you will encounter. We've included proven strategies to help you successfully tackle these complex insurance situations.

1. Coordination of Benefits: Primary vs. Secondary Insurance Strategies

Patients may have two insurance policies due to multiple employment-based coverages. Or, they may have a mix of private and public insurance, such as Medicare and private insurance. For these patients, coordination of benefits (COB) determines which plan pays first and which covers extra costs.

In 2021, 43.1 million people, or about 13% of individuals, had more than one coverage type, emphasizing the need for efficient COB management.

Utilize Automated Insurance Discovery Tools

Automated insurance discovery tools streamline the COB process. These tools automate insurance discovery steps to find which insurer is primary or secondary. This helps reduce claim errors and prevent unnecessary claim denials.

Educate Patients on Their Multiple Insurance Policies

Educating patients about their insurance hierarchy helps avoid payment delays and billing surprises. A clear explanation of their primary and secondary policies is key. It helps them understand which plan will cover specific services and which costs may still be their responsibility.

Train Your Hospital Staff to Handle Coordination of Benefits

Ensure staff are well-trained in COB handling to prevent missteps that can delay reimbursement. Comprehensive COB training should include, at minimum, the following:

• policy verification procedures
• guidelines for collecting patient insurance information
• steps to process claims under multiple insurers

2. COBRA: Insurance for Patients In Between Jobs

Patients transitioning between jobs may rely on COBRA coverage. This insurance extends employer-sponsored health insurance for a limited period. COBRA can help maintain continuity of care but can be tough for providers to manage.

Preauthorize Services to Avoid Claim Denials 

Confirm that the patient's COBRA coverage is active. Then, verify any service requirements before scheduling or delivering care. Preauthorizing services for COBRA-covered patients helps ensure claims are not unexpectedly denied. 

Provide Financial Counseling to Patients

COBRA patients may need financial counseling and education. This extra step helps them understand their coverage limitations and potential costs. Financial counselors can help explore payment plans, available subsidies or alternative coverage options. These options could ease their financial burden.

Regularly Verify COBRA Coverage

COBRA coverage is temporary and can expire if the patient misses payments or reaches the maximum coverage duration. With this in mind, routinely verify COBRA status. Doing so helps manage patients who may inadvertently lack active insurance and not know they are categorized as self-pay. Add an insurance eligibility verification check during pre-registration to confirm active coverage.

3. Special Enrollment Period (SEP)

Government-sponsored healthcare plans have special rules. Patients can only enroll in a new plan outside of the standard enrollment window if they qualify for the Special Enrollment Period (SEP). Patients who experience life events are eligible for SEP. These life events might include a job loss, change in household, change in residence or other significant income change. SEP eases coverage transitions during these difficult times. It also ensures continued access to healthcare. 

Develop Partnerships with Insurance Navigators

Collaborating with insurance navigators facilitates SEP enrollments. It also ensures patients find the best coverage options. Navigators can guide patients through the process by checking if their application is accurate. They can also help them choose an appropriate plan given their new circumstances. 

Ensure Eligibility Verification Before the Patient’s Visit

Like COBRA, providers can incorporate SEP checks during pre-registration. Conduct SEP insurance eligibility verification before a patient's visit. Doing so prevents delays in coverage and protects providers from unpaid medical claims. 

4. Cross-State Insurance Coverage

Patients needing healthcare services in different states often face coverage challenges. This is especially true in non-emergency cases. Employers may offer multi-state plans that cover employees no matter what state they live or work in. However, they may not cover the same services in every state or offer adequate in-network providers.

Leverage Emergency Care Protections for Reimbursement

EMTALA and the No Surprises Act help hospitals in these emergencies. Providers can seek reimbursement for this emergency care, regardless of state residency. Familiarize yourself with these protections to ensure fair compensation for cross-state emergency care.

Preauthorization for Non-Emergency Care

For non-emergency care, obtaining preauthorization can prevent unexpected billing issues. It also ensures compliance with the patient’s policy requirements.

Create Cross-State Insurance Policy Database

Maintaining a cross-state insurance policy database is essential. It allows staff to reference state-specific requirements, policies, and coverage networks. This centralizes the information, making it easier to verify benefits.

5. Health Insurance Coverage Gaps

Healthcare providers frequently encounter patients with temporary lapses in insurance coverage. These circumstances often result in reimbursement challenges. Hospitals handle these situations on a case-by-case basis. The solution depends on several factors, including the point at which the patient might regain more stable coverage. 

Offer Patients Flexible Payment Plans

Offering flexible payment plans can be a major asset for patients with coverage gaps. It helps them manage costs while ensuring providers receive payment. These plans make healthcare more accessible and reduce financial strain for everyone.

Enable Patient Access to Temporary Coverage Options

Short-term insurance policies and temporary coverage options should be accessible to patients. These options can bridge the gap until patients secure long-term coverage. However, short-term policies usually come with drawbacks. Common ones include significantly higher deductibles, limited coverage and many highly varied options. These options can prevent financial hardship and ensure continued access to necessary care. However, it’s important to prioritize patient education to make sure they understand anticipated costs.

Schedule Non-Urgent Care During Their Next Coverage Period

When possible, schedule non-urgent care during the patient’s next active coverage period. Doing so can prevent them from incurring high out-of-pocket costs. This approach increases the likelihood of patient follow-through and prevents unexpected expenses.

6. Out-of-Network Care & Unexpected Costs

Out-of-network providers do not have a contractual agreement with a specific health insurance plan. Because they are outside the insurance network, they typically charge higher service fees. A patient’s insurance plan may not fully cover these charges.

Inform Patients of Their Out-of-Network Status

Transparency regarding out-of-network status empowers patients to make informed decisions about their care. Clear communication about costs, coverage gaps and alternatives is key. It helps reduce billing disputes and potential loss of revenue.

Negotiate Partial Payment from Insurers

In some cases, providers can negotiate partial payment from out-of-network insurers. This step can offset costs and secure some reimbursement. This is especially true in cases where in-network options are unavailable.

Help Patients Balance Billing Appeals

Patients not expecting such a high cost may contest some of the charges on their billing statements. Guiding patients through the hospital’s appeals process shows commitment to patient advocacy. At the same time, it helps providers potentially recover more reimbursement.

7. High-Deductible Health Plans (HDHPs) and Health Savings Accounts (HSAs)

High-deductible health plans (HDHPs) are increasingly popular. However, they require patients to cover large out-of-pocket costs. Like many of the other options on this list, payment plans and patient education can help settle medical bills sooner rather than later.

Advise Patients on How to Use HSAs for Eligible Medical Expenses

HSAs cover many medical expenses, providing patients with tax-free funds for healthcare costs. Educating patients on eligible expenses helps them make the most of their HSA. It can also potentially reduce out-of-pocket costs.

Provide Patients with Transparent Pricing

By providing clear cost estimates, providers can build trust and reduce the likelihood of unpaid bills due to sticker shock.

Offer Payment Plans for Out-of-Pocket costs

Offering payment plans for HDHP patients helps reduce their immediate financial burden. It makes healthcare more affordable and prevents outstanding balances.

Maximizing Reimbursement in Every Scenario

Managing complex insurance scenarios requires a proactive approach. However, you have noticed a pattern as you read. Most scenarios can be effectively managed with knowledge, proactivity, and the proper tools.

Office Ally’s tools and software solutions help hospitals and health systems to navigate these challenges. We help reduce revenue recovery challenges and enhance patient satisfaction. With Office Ally’s solutions, healthcare providers can streamline complex insurance management. This support creates a smoother patient experience and more consistent reimbursement. 

Click here to learn more about Office Ally’s suite of solutions designed to optimize your insurance management practices and maximize revenue recovery.