Effective and Collaborative Communication with KPD Denise Shamblin, BA, CCS, CRCR Sharp Memorial Hospital

Importance of Effective and Collaborative Communication Unintentional financial harm to Donors Provider accounts receivable (AR) ages unnecessarily Insurance barriers SRS Case Study Best practices Secure communication to coordinate coverage Donor education Verification of accounts Validation of Health Plan’s ability to participate Open communication with providers and payers Medicare Replacement HMO and Medi-Cal HMO Case Studies

Unintentional Financial Harm to Donors Unintentional financial harm to Donors when insurance and/or billing instructions have not been communicated to all providers involved in Donor care Donors get billed Multiple collection calls from unaware Patient Financial Services (PFS) staff Some actually get sent to collections

Aging Accounts Receivable Providers AR ages unnecessarily Unproductive staff hours Reimbursement delay Possibility of unneeded collection calls

Insurance Barriers Several plans will not cover out of state participants Sharp Reese Steely (SRS) Case Study SRS is a local San Diego HMO that follows normal HMO rules. Services must be provided within 60 miles of the primary care physician Patient was enrolled in KPD and the exchange was scheduled when it was noted that the plan would not cover the transplant Facilitation of communication between SRS and the Donor center led to a letter of agreement (LOA) and a successful transplant Led to a change in internal processes, which became a best practice

Best Practices A secure group email is sent to providers with the billing instructions on all transplants, including KPD transplants. Email includes subscriber ID, claims mailing address, name and DOB of recipient and authorization if applicable. If a Global Plan, those instructions are included as well. Physicians don’t work directly for the hospital and so were not aware of the specialty billing practices for Living Donors. Coordination of billing practices has reduced the number of Donors sent to collections by 99%.

Best Practices Educating our Donors in regards to billing practices of outside providers. Donors should not be billed. Period. However, if they do receive a bill, they should contact the Transplant Coordinator or Financial Coordinator immediately. We now have a dedicated financial coordinator that will be responsible for Donor financial education and handle all associated claims.

Best Practices We have much more control when services are provided at our Center. Most of the pre and post encounters are opened by our Financial Coordinators and accounts are set up so that the Donor will not receive any bills. As all accounts related to transplant are reviewed by our Revenue Cycle Manager prior to being billed, accounts can be verified to ensure correctness and make any changes, if needed, prior to the claim being dropped.

Best Practices Before consideration of KPD is offered, the transplant financial team verifies and validates the Health Plan’s ability to participate. The account is noted by the Revenue Cycle Manager that participation has been approved and the Donor may move forward. This information is communicated to the entire Living Donor Team and noted in the patient’s transplant record to ensure it is available to everyone. This has prevented last minute cancellation of KPD chains due to insurance coverage issues.

Best Practices Working with all plans that have some hesitation regarding the participation with KPD. This does require a willingness to educate both the Medical Directors and the Nurse Case Managers about the KPD process, benefits and cost reduction Case Studies

Best Practices Medicare Replacement HMO Medi-Cal HMO Patient with a Medicare Replacement HMO was enrolled into the KPD Communication with the Health Plan Medical Director and Quality Director revealed that they had wanted to participate in the program, but had yet been presented with the opportunity Had our team not reached out, the transplant would not have occurred. This exemplifies the importance of open communication with other payers and providers. Patient with Medi-Cal HMO was enrolled in KPD Communication with the Health Plan Medical Director revealed that they would not be willing to cover Donor services outside of the state Discussion with the CFO resulted in Sharp covering the donation services Our team continues to communicate with the plan in hopes that KPD Donor coverage may become a practice as waitlist times increase

Importance of Effective and Collaborative Communication Unintentional financial harm to Donors Provider accounts receivable (AR) ages unnecessarily Insurance barriers SRS Case Study Best practices Secure communication to coordinate coverage Donor education Verification of accounts Validation of Health Plan’s ability to participate Open communication with providers and payers Medicare Replacement HMO and Medi-Cal HMO Case Studies

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