Patient Access Analyst, Oncology

Patient Access Analyst, Oncology

The Patient Access Analyst, Oncology provides assistance to patients, physicians, caregivers in all areas of Oncology/Radiation Oncology services in the HMH Health care system. This pertains to Prior Authorization for Oncology services, as well as various specialized services ordered by clinical caregivers which may require prior approvals to avoid loss of revenue for both professional and facility services and surprise out of pocket costs. This position is responsible for coordinating all the functions and activities related to patient precertification/authorization for Chemotherapy, Radiation, and Diagnostic Imaging associated with a patient's plan of treatment. This includes but is not limited to: accurate and complete patient registration in the approved organization electronic scheduling and billing systems and on-site insurance verification while being able to navigate the various Insurance portals where clinical data is submitted to substantiate the request for prior approvals for oncology services.

Responsibilities

• Obtains Referrals/Authorizations and Verifies eligibility, submits requests for prior authorizations for all oncology services as prescribed by the Clinical care team and conformance to Hackensack Meridian Oncology/Radiation standards and protocols within the network.
• Submits all referral information to necessary providers, as appropriate. Assists with pre-authorizations of hospital admissions, procedures, medications and medical equipment.
• Maintains ongoing communication with insurance companies to determine eligibility of benefits, deductible status, and to obtain precertification for office-based and other procedures.
• Educates and informs patients and families regarding verification status and issues related to deductibles, co-payments and balances.
• Responds to hospital staff and/or patient inquiries regarding referrals, authorizations and scheduling in an efficient manner.
• Resolves all outstanding Alerts on pending appointments within 48 hours of the scheduled appointment to minimally include: Missing Referral Missing Pre-certification/Authorization Self Pay Accounts Eligibility Verification Missing Demographic/Insurance Information.
• Determines if the appointment needs to be rescheduled due to missing Referral or Authorization number. Works with departmental supervisor and/or clinician to determine medical necessity and if the appointment can be rescheduled. If appropriate, notifies the patient that the appointment needs to be rescheduled due to missing Referral/Pre-certification/ Authorization.
• Analyzes patient Medical record by searching and reviewing medical history records to ensure all clinical information is documented and gathered to be sent to insurance companies for proper review of all authorization
• At the time of newly created treatment plans for both Radiation, Pharmacy or complex service(s), review plans and cross reference the patient's insurance benefits to determine out of pocket calculations for those anticipated services.
• Summarize pertinent information in Epic Insurance Benefits verification notes field in appropriate manner so that information accurately communicated to patients regarding their specific out of pocket expenses for new treatment plans.
• Document both in-network and out-of-network benefits in order to allow Patient Access Specialists to accurately communicate information to patients. Make referrals to Financial counselors when appropriate.
• Maintains regular communication with patient's clinical care teams. Identify and understand all modifications to those plans by use of the Epic Beacon Pharmacy work que. Obtain new prior authorizations when needed in order to avoid technical denials for lack of prior authorization. Understand if payer rules governing when or if a prior authorization is required should a treatment plan change.
• Follow Medicare rules for medical necessity and inform clinical care teams and any others, if a plan has failed medical necessity requirements, document the treatment plan and follow ABN mandates and rules. Inform patients of options as defined by the ABN advance beneficiary notice in alignment with Medicare guidelines.
• Document prior authorization requirements in each referral by each CPT or J code as required so that both the Pharmacy and staff in patient financial services are able to understand which treatments are approved and the duration of that approval.
• Understand and properly communicate whether treatment plans provided will meet medical necessity regardless if prior authorization is required.
• Acts as Liaison between Financial counselors and assigned vendors. Document estimated out of pocket cost for treatment, status of treatment and authorization status in appropriate format for vendor review.
• Provide clarification to clinical care team if clarification is needed as to if a drug is to be covered and approved by any patient's insurance.
• Act as liaison between vendor and patient in order to obtain necessary signatures of clinical staff, document in the appropriate Epic field and scan into media manager.
• Input proper documentation into Beacon referral shell as to what Drugs are approved for replacement and which are to be taken from hospital supply to ensure and safeguard financial risk to the HMH healthcare system
• Obtain prior authorizations for all diagnostic imaging and various outpatient services for Oncology and any other patients during and after their treatment if ordered by any attending physician or their practice of whom have a business agreement for these services with HMH.
• Review accounts to ensure that the proper CPT(s) codes are billed to the Insurance carrier accurately & timely.
• Prioritizes bed assignment in accordance with policy.
• Ensures patients are assigned to the proper unit according to admit order.
• Reviews orders to ensure the patient is in appropriate status and level of care.
• Initiate real time eligibility query (RTE) on all eligible insurances. Must review RTE response to ensure correct plan code assignment and correct coordination of benefits to facilitate timely reimbursement.
• Ensure accurate completion of Medicare Secondary Payer Questionnaire.
• Performs insurance verification on all Inpatient and Outpatient services, and determines the patient's out of pocket responsibility via the EPIC Financial Estimator tool using the applicable data.
• Where appropriate, pursues upfront cash collections to assist patients in understanding their financial responsibilities and minimize overall bad debt.
• Informs patients of their out of pocket responsibility taking payment via credit card or in person and explaining financial resources including financial assistance, payment plans or payment on date of service.
• Verifies benefits to ensure the procedure is a covered service under the patients plan prior to receiving services.
• Verifies pre-authorization requirements and follows up with both the referring physician and payer to ensure authorizations are on file for the scheduled procedure prior to date of service.
• Submits all data timely, effectively and expeditiously for all treatments and procedures to ensure authorizations have been obtained and determine that the procedure or treatment is authorized prior to date of service.
• Ensures diagnosis data that is entered on registration is accurate and meets medical necessity criteria.
• Complies with HMH's patient financial responsibility and collection policies.
• Provides patients with appropriate administrative information, as directed.
• Maintains compliance with federal/state requirements and ensures signatures are obtained on all required regulatory/consent forms.
• Manually registers patients accurately when in `downtime' mode and properly follows registration input procedures when the system becomes available.
• Attempts to mediate daily scheduling, pre-registration, pre-certification or registration issues and elevates any issues that cannot be resolved independently.
• Completes assigned work queue (WQ) accounts in a timely and efficient manner.
• Assumes other responsibilities as directed by either the Supervisor, Manager or Director of Patient Access.
• Identifies the needs of the patient population served and modifies and delivers care that is specific to those needs (i.e., age, culture, language, hearing and/or visually impaired, etc.). This process includes communicating with the patient, parent, and/or primary caregiver(s) at their level (developmental/age, educational, literacy, etc.).
• Ensures delivery of excellent customer service resulting in a positive patient experience.
• Complies with all procedural workflows and departmental policies and procedures as identified.
• Responsible for scanning any documents and correspondence from patients and payers.
• Coordinates daily activities of the Patient Access Department which fosters an environment promoting patient comfort and trust.
• Have the ability to schedule patients as needed.
• Answers a high volume number of phone calls and responds in an appropriate/professional manner. Address and resolve any issues quickly/accurately.
• Ensures timely notification of admission to payers and refers accounts to Case Management for timely submission of Clinical Information to payer.
• Verifies eligibility and benefits to ensure patient's coverage is active and that the procedure is a covered service under the patient's plan prior to the date of service.
• Verifies pre-authorization requirements and follows up with both the referring physician's office and payer to ensure authorizations are on file for the scheduled procedure prior to the date of service.
• Able to access and navigate various payer websites (e.g. Navinet) to confirm patients insurance coverage and policy benefits.
• Works with patients to financially clear their account per policy at least 3 days