Association News

Artificial Intelligence is Well-Advised to Handle Medicare Enrollment Challenges for Hospitals

Ensuring optimal patient access is always a challenge for hospitals and hospital staff. Securing prior authorization for procedures takes a lot of staff time. Often, these procedures get denied or delayed while staff determines coverage. Many times, procedures are referred and then determined to be out-of-network, requiring more out-of-pocket expenses for patients who usually cannot afford the costs. Hospitals either “lose” the procedures when the patient isn’t covered, or they must set up a long-term payment plan with the patient that goes into bad debt.

During inpatient admissions, many insurance plans (including Medicare) determine the length of stay hospitals will be reimbursed. Most of Medicare reimbursement for hospitals is based on a diagnosis, not a daily rate. The hospital receives one fixed rate for all services needed to care for the patient, dependent upon the diagnosis code. However, every day over the provided days is not reimbursed — and falls to the bottom line of the hospital. Each “avoidable day” can cost a hospital $300-$500 to provide the patient basic necessities.

Optimal patient access is always a priority for hospitals. Health care professionals want to assure that all patients have access to care to meet their clinical needs for every life event they face, whether outpatient, inpatient, post-acute care, or long-term care. When patients have insurance coverage for the right care, with preferred providers, this supports clinical excellence. It also results in the reduction of bad debt by decreasing out-of-pocket costs for patients.

Hospitals often don’t relate patient access directly to the Medicare coverage that patients select, but there is a significant correlation. When enrolling in Medicare, 94 percent of people don’t choose a plan that is optimal for their clinical and financial needs. And, 87 percent of people never change plans, despite changes in clinical conditions or other life events. Pairing each patient with optimal coverage aligns to better clinical care for patients and better financial health for hospitals.

The tech world has been working to solve the challenge of patient access, helping to ensure that Medicare-eligible patients are able to be matched to the single-best Medicare plan that best aligns with each patient’s clinical needs, hospital and provider preferences, and budget.

HASC partnered with Well-Advised as an Endorsed Business Partner to ensure that its hospitals have access to this free, non-biased, A.I.-driven confidential recommendation tool. As hospitals refer patients to Well-Advised, patients will have optimal coverage for their clinical needs, which will lead to both improved patient satisfaction and a positive impact on hospital finances.

To learn more about how Well-Advised can benefit your hospital and patients, listen to our recent podcast or contact Darryl Sanford, HASC director, member relations and association services (below). 

Well-Advised COO Mimi Roberson can answer specific questions about the platform at [email protected] or (303) 246-8883.