When medical bills overwhelm them, some patients turn to patient advocates who are trained to work with providers and payers to identify coverage and payment options.
Revenue cycle staff need to understand how to work effectively with medical bill advocates-to the benefit of patients and the hospital alike.
Meet the Advocates
Patient advocacy-or patient navigation-is a growing field. As highlighted in the May 2009 Patient Friendly Billing, patient advocates provide a wide variety of assistance-from accompanying patients to medical appointments to handling billing and medical debt issues.
Many hospitals have their own patient advocates. However, some patients seek the assistance of external patient advocates. Two types of external advocates may contact hospital financial staff:
- Advocates from not-for-profit organizations who help certain types of patients, such as those with specific diagnoses
- For-profit advocates who are hired by patients with medical debt problems or other issues related to their hospital care.
The Perspective of a For-Profit Advocacy
The field of medical billing advocacy as a specialty is growing as more patients with high-deductible or limited benefit plans find themselves responsible for larger portions of their medical expenses. They seek out advocates like Shari Samotin, president of AttackMedicalBills.com, to help manage a debt crisis without going into bankruptcy.
"Most patients are appreciative of the care they received, and they understand that they have a responsibility to pay a bill for that care," she says. "And most patients are not looking for a way to stiff the hospital."
That said, the patients who hire medical bill advocates do not want to pay the entire amount on the bill they received-and Samotin, a former medical practice administrator and employee benefits manager, thinks it is unlikely that they should have to.
"I want my clients to pay a fair and reasonable price for a true and correct bill," she says.
Samotin is a member of Medical Billing Advocates of America. Founded in 1997, that group includes about 100 billing advocates. Working only with clients who are willing and able to pay a portion of the medical bills they have received, Samotin uses a multistep process to reduce their obligations.
Review medical record. First, she compares the physicians' orders from the patient's medical record to the detailed itemized statement. "How often do I find billing errors? Most of the time," she says. "As far as I'm concerned, if something was not ordered, it comes off the bill."
Samotin cites a client who was charged for several days of telemetry for which there was no record of a physician's order. "We're not denying that the patient received the telemetry service. She probably did," she says. "But the doctor never ordered it, so that kind of error is pretty easy to get resolved."
Identify inappropriate charges. Next, Samotin looks for opportunities to "unbundle" charges that are generated automatically-and would be discarded during the insurance adjudication process.
This kind of charge is not necessarily an "error," but rather what Samotin considers to be an inappropriate charge. She gives the example of hospital gowns, which get barcode-scanned for inventory control purposes.
"Therefore, each gown appears as a charge, and if you have insurance, the insurance company's computer would throw it out because the gown is covered in the daily room rate," she says. "But when you're an uninsured or self-pay patient, you don't know that. I find tons of stuff like that."
If a patient has insurance, Samotin may ask the insurance company to re-process the patient's bill after it has been "cleaned up" to her satisfaction. For a patient with 20 percent coinsurance, the out-of-pocket obligation can change dramatically if a total bill is reduced by several thousand dollars, which frequently happens.
Negotiate lower rate. After Samotin is convinced that the bill is fair, and the insurance benefits are exhausted, she explores a patient's options for negotiating a lower rate from the hospital. Among other factors, this depends on state laws, the hospital's policy, and whether treatment was provided by a for-profit or not-for-profit hospital.
"If my client can potentially qualify for hardship, then I will help fill out the hardship application and bird-dog that through until we get an answer," she says.
For clients who do not qualify for hardship, Samotin negotiates with the hospital on behalf of the patient with the goal of identifying an amount the hospital is willing to accept and the patient is able to pay.
The Perspective of a Not-for-Profit Advocate
The largest not-for-profit advocacy group is the Patient Advocate Foundation. Since 1996, it has been helping patients with chronic, debilitating, and life-threatening diseases deal with three types of issues: access to care regardless of insurance status, job retention, and medical debt.
In 2009, the foundation's case managers served 55,384 patients nationwide, and nearly two-thirds of those patients reported a debt crisis because of their medical expenses.
"Eighty-one percent of the patients who experienced a debt crisis were fully insured," says Erin Moaratty, the foundation's chief of external communications and a long-time case manager. "There is such a misconception that the uninsured patients are the ones who have debt crises, but we are serving the under-insured population more frequently because so much of the financial burden is being placed on consumers."
Medical debt crises sometimes arise because patients do not communicate well with hospital financial counselors or do not understand the billing process. In other cases, patients are simply too sick to gather and focus on the information they need to provide. Successful advocacy means facilitating communication so that patients get the care they need and healthcare providers get the money they deserve, says Moaratty.
"Our success comes from being that third party, where patients feel comfortable giving us all of their information so we can, in turn, ask the right questions to the hospital staff," says Moaratty.
The foundation's case managers typically speak to a hospital staff member in a conference call with the patient. The case manager mediates the conversation, serving as an advocate to the patient and to the facility that needs to be paid for services rendered.
"Our main goal is to help get reimbursement from an insurer. We are not simply out there to find charity care or write-off discounts," says Moaratty. "We're looking to make sure no stone is unturned. Is there a coding and billing solution? Is there an insurance appeal option?"
Beyond that, the case manager explores options available through the hospital as well as outside resources, such as drug reimbursement programs, government programs, or grants that might apply to a patient's individual situation.
How to Work with Advocates
Samotin finds that patients who request additional information about their medical bills often receive a patient-unfriendly response. "Don't assume that because somebody wants to be an informed and empowered patient/consumer, that they are trying to stiff you," she says.
Train frontline staff how to respond to advocates' requests. Hospitals are required to provide patients with a copy of the UB-04, the uniform billing form used for insurance companies. Uninsured patients are entitled to the information that would have been on an UB-04 form. But frontline staff members are not always trained about those documents and patients' rights.
"A lot of the time when I request a UB-04, or I request something that shows CPT codes and ICD-9 codes, I might as well be speaking Greek," she says. "They don't even know what I'm talking about."
If the patient or advocate asks to speak to a supervisor, another type of resistance is frequently encountered. "They immediately become defensive and ask, 'What do you want it for?'" she says. "I think they are trained to worry about, 'Are we about to get sued?' But if a patient is planning to sue, they would have had an attorney request this documentation."
Develop fair payment policies. She believes the most patient-friendly way for hospitals to work with self-pay patients would also be the most financially advantageous for the hospital: adjust the patient's charges to the rates that insured patients are charged before the bills are sent.
Samotin points to a hypothetical case of a $50,000 bill delivered to a self-pay patient that would have been $19,000 if the patient was insured or a Medicare beneficiary.
"If I get a $50,000 bill and I make $50,000 a year, I'm probably going to just ignore the bill because there's no way I could pay that off. I would think, 'Go ahead and send me to collections,'" she says. "On the other hand, if that bill is $19,000, some people would say, 'OK, let's start from here. How can I make a dent in that?'"
The other argument for adjusting self-pay bills is to reduce the risk of bad publicity and patients' distrust of the hospital. Pointing to the most high-profile example-CNN's Prescription for Waste series that reported hospitals charging $1,000 for a toothbrush and $140 for a single Tylenol®-Samotin says that negative publicity implicates all hospitals. "That CNN series put everybody on the defensive because all patients assume they're being overcharged," she says.
Publication Date: Tuesday, November 16, 2010