Billing, Referrals, Resource Identification, and Scheduling
call us at 423.232.6700
extensions 100, 101, or 107 will direct you immediately to our administrative staff
Project Access is organized to not only assist the provider but the entire medical office. By assist, we mean utilizing the methods already in place in most offices (entering Project Access as an insurance code) and relieving staff of the additional responsibilities that may come with providing service to the uninsured (calling in a favor so that a patient may see a Specialist or finding the number for the local Food Stamp office).
As a Billing or Patient Accounts Representative what am I expected to do for Project Access patients?
1. Submit Claim Forms to our office. [HCFA/CMS-1500 or UB-92]
Most offices prefer to assign Project Access an account code similar to insurance companies. Claims associated with this code are then easily identifiable, and can be pulled and sent to our office (via fax, email, or traditional mail depending on the provider’s preference).
2. Write-off as an In-Kind Donation
All participating providers offer their services at no cost to the patient. So, though we may be coded as an insurance company, we are not an insurance company and do not pay for any services rendered. It is important that you remember to write-off the amount of any claims being sent to our office.
Exception: Project Access will only accept Claim Forms for approved services. It is important that your staff confirm that a particular service has been authorized (not just that the patient is enrolled and carries a card). Please call our office to request or confirm an authorization code for the particular service. Should a Claim Form be returned to you, please assign it to the patient’s account as self-pay. Repeated use of non-approved services will result in a patient’s disenrollment from our program.
Claims – Our Keys to Tracking, Reporting, and Funding
Tracking – Claim forms allow us to observe trends in diagnoses, to distribute levels of patient need evenly among providers, to spot billing errors, and detect inappropriate or fraudulent use of Project Access services.
Reporting – Claim forms allow us to calculate the specific amount of donated care to report to the State, to tally the amount of potential tax deductions available to our providers as out-of-pocket expenses, and to demonstrate our participating providers’ public commitment to our community.
Funding – Claim forms hold our organization accountable to our funding sources, help us secure other government and non-government funding opportunities, confirm the importance of our organization to the community, verify the efficiency of our organization through return on investment calculations, and influence legislators when considering topics of particular interest to their healthcare constituents.
Back Dating – Available Upon Request
We will allow a patient’s enrollment to be backdated up to 90 days when the provider requests this and if there is a connecting event to tie it to (for instance, the patient’s first visit to your office or the initial date of hospitalization). For consideration, a provider simply needs to write “Please Back-Date” on the Referral Form itself.
Example: Your patient is determined eligible for our program and given a start date of 09.04.2012 [start dates are based on the actual date the patient meets with his/her Care Manager for the Initial Enrollment Appointment at our office]. The patient was first seen by your office on 08.10.2012. You can request that the Enrollment Period (and the patient’s issued Access Card) reflect a start date of 08.10.2012. Remember, to send us any claims during the time period being back-dated and write-off the charges internally.
The need for referring a patient to a specialty care provider is often the time when favors are called in. The traditional “I saw a patient of yours back in the day, will you return the favor? With Project Access, there is no need to do this for the low-income, uninsured. Time spent tracking down providers and getting verbal commitments can be redirected more effectively and efficiently. That’s because we do it for you. You refer your patient to our program and we make sure they are connected with the next available provider in the area being requested.
Behind the Scenes – The Importance of Allowing Us to Complete the Referral Process
1. Limited Commitments
Project Access requests that participating providers complete an annual Participation Plan. This Participation Plan outlines the number of Project Access patients that the provider(s) agrees to see. We do not ask a provider to increase the level of his/her Participation Plan once it has been submitted/agreed upon.
2. Tracking & Rotation
Project Access enters all Participation Plan information into our database, so that we can track total commitments, commitments by specialty/area, and commitments by region. Then, our software enables the rotation of providers as commitments are used, so that one particular office is not bombarded with requests.
3. Point of Contact
Often the low-income, uninsured are not able to afford an initial appointment to become established with a provider. Project Access, therefore, considers providers with whom a patient has been previously established with but also providers with whom a point of contact has been made. A consultation may be considered a point of contact.
Example: Your office meets with a patient and determines that he should be seen by a Neurologist and a Rheumatologist. Your office refers the patient to Project Access but decides to go ahead and suggest that the patient see Dr. Synapse and Dr. Cartilage. Dr. Synapse does participate with our program. Dr. Cartilage does not. The patient schedules with both of these offices the week before the Enrollment/Initial Intake Appointment with our office.
When the patient calls Dr. Synapse’s and Dr. Cartilage’s offices, he tells them he has no insurance and is entered into their system as self-pay. The patient is then either expected to pay all (or part) of the charges up front or is billed for all (or part) of the charges later. At this time, the patient mentions that he has been referred to Project Access.
Scenario A – Dr. Synapse’s office decides to charge the patient anyway (since he was understood as self-pay). This may cause the patient’s intentions to be called into question by Dr. Synapse’s office…did he say one thing to be seen and then say something else to avoid paying for the services? This can create confusion for the patient, who understood Project Access to be a program able to connect him with donated medical services. This confusion can lead to mistrust, which hinders our ability to positively engage the patient. This visit to Dr. Synapse’s office is also a point of contact. Our policies do not allow us to then refer the patient to a different Neurologist.
Scenario B – Dr. Synapse’s office can decide to code the visit as Project Access, consider the patient a commitment, and send the claim form to our office. Dr. Synapse, though participating, may not have anymore commitments left…does he agree to see this additional patient? and does he feel at all pressured or tricked into doing so? Dr. Synapse, may have commitments left, but may not be the next provider on rotation. His office may have planned for up to 2 Project Access patients each month, but this patient (out of the rotation cycle) makes 3. This may cause unnecessary tension on Dr. Synapse’s relationship with our office, which ultimately can affect his next Participation Plan. On the other hand, Dr. Synapse may have no problem accepting this “third” patient, but a different patient with a more urgent need for his services may have to wait or go without. Another issue may arise should the patient be screened by our program yet fail to qualify. For instance, his Care Manager has found his household to be at 250% of the Federal Poverty Level (Project Access’s limit is 150% FPL).
Scenario C – Dr. Cartilage’s office charges the patient as self-pay. See Scenario A for how this might play out.
Scenario D – Since Dr. Cartilage is non-participating (meaning he has not agreed to a Participation Plan with the Project Access program), we would attempt to recruit him. Should Dr. Cartilage decide not to participate, the patient has had a point of contact with a Rheumatologist who will not donate services. Based on the concept of equitable distribution and shared responsibility, Project Access does not transfer patients from provider to provider within the same specialty area. This means that Dr. Autoimmune, an area Rheumatologist with a different practice, would not be asked to see the patient simply because Dr. Cartilage has chosen not to.
Organizations excel when professionals are able to exercise their knowledge and flex their expertise in a focused, concerted effort. One might suggest that specialized training in various fields gives those particular individuals an edge, an advantage, or increased value in specific circumstances. Your computer goes down…probably want I.T. Your water line breaks…probably need that Plumber. Got a mass that needs removed…going to call a Surgeon. If you take any of these people and ask them to cover one of the other’s responsibilities, they are going to experience a disconnect and dissatisfaction.
Many medical offices end up assigning non-medical tasks to their staff simply because the tasks are important and there is no one else to do them. Project Access includes resource identification, information, referral, and follow-up for a variety of supportive services, social services, and community-based resources, via social work trained Care (Case) Managers. In 2011, our Care Mangers made 6,263 referrals for indirect medical or non-medical services in areas such as dental care, prescription assistance, mental health, clothing, and food. We have worked with companies to secure orthopaedic replacement parts, prostheses, medical equipment, and medical supplies. We assist patients with navigating social service applications, negotiating barriers, and problem-solving particular limitations.
You provide the medical. We’ve got the social.
At each Enrollment or Re-Enrollment Appointment, patients are asked to complete a Needs Assessment. This forms simply lists areas of potential need that a patient can check for more information. If the form does not include a particular area, the patient can write-in his/her own particular need. The Needs Assessment is also a helpful tool to launch conversation about a patient’s indirect medical or non-medical needs during the Care Management Appointment itself. Patients are sent a follow-up Resource Letter with all the area’s applicable resources, contact information, locations, requirements, and restrictions.
The act of scheduling an appointment appears straightforward on face-value…you make a phone call, provide some demographics, and select a time slot. For those who actually schedule appointments, you know differently. Sure there are a standard set of questions such as name, date-of-birth, and contact information, but each office also has specific questions that are important to them. Some offices require certain forms; others, that records be sent before an appointment will be scheduled. Then there is the records request (items you need to track down from another office) and the records transfer (items from your office that you need to send). The patient will need to be contacted with the appointment information, and any specifications (such as no food or drink by mouth after midnight or bring your medication list). Then there is the follow-up work…did the patient keep the appointment? was is rescheduled? was the procedure able to be performed? will the patient need continued care?
Scheduling (diagnostics and initial specialty care appointments) is one way we can specifically help ease your load. Project Access, through its relationships with our participating providers, has established pathways which take into account providers’ preferences and needs regarding the low-income, uninsured. We know which providers we can refer to, how many patients they are willing to see, how many commitments are remaining for the year, etc. [For more information, see the Referrals section above.]
After we schedule an appointment, we will make sure to update your office regarding the details. We contact the patient with the information, and even send an appointment reminder notice. We always send the referring provider’s information to encourage communication between the offices, but are also available to facilitate information sharing as appropriate (such as when the secondary provider wishes the patient to be seen by a third).
Scheduling also helps us track who we should be receiving claim forms from. [For more information, see the Billing section above; specifically Claims].