At a Glance
Steps to take in determining whether your organization's financial assistance eligibility program should be revamped include the following:
- Conduct a "gap analysis" to evaluate your organization's specific needs.
- Communicate with other facilities that have faced similar problems to uncover what solutions worked-or didn't work-for them.
- Recognize that identifying coverage for the underinsured and uninsured requires a special skill set.
Although the recession is purportedly over, the impact of the economic crisis continues to be felt across the country. With unemployment at record levels, a growing number of Americans find themselves without health insurance. Although the Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers who lose their jobs the right to maintain health benefits for themselves and their dependents, many individuals who are unemployed cannot afford to continue paying premiums and therefore begin to rely on the emergency departments (EDs) of their local hospitals as their primary source of care. As a result, hospitals across the country are reporting an unprecedented increase in uninsured ED visits and are providing more uncompensated care than ever, adding to the financial strains hospitals already face.
At Ochsner Medical Center, a not-for-profit, 200-bed facility in Baton Rouge, La., helping self-pay patients determine whether they qualify for financial assistance became a necessity when the number of patients presenting to the ED increased by more than 5,000 over the previous year-and 10 percent of these patients lacked healthcare coverage.
Like many U.S. hospitals, Ochsner relies on eligibility experts to identify patients who might benefit from financial assistance programs such as Medicaid and/or Medicare, Supplemental Security Income (SSI), and other lesser-known programs, like those available through the Louisiana Crime Victims Act, to offset at least a portion of the cost of care.
In its early efforts to locate coverage for self-pay patients, Ochsner created a full-time position dedicated to working with patients to determine eligibility for financial assistance programs. It soon became apparent, however, that hiring a single person to handle such efforts would not be sufficient.
The hospital determined that, to effectively guide an increasing number of self-pay patients toward financial assistance programs that could help pay for their care, it would need to restructure its financial assistance eligibility program. Doing so has led to a 22 percent increase in the number of self-pay patients identified as being eligible for assistance-and has enhanced the hospital's bottom line.
Restructuring the Hospital's Financial Assistance Eligibility Program
When Ochsner undertook its initiative to develop its financial assistance eligibility program in 2007, the hospital focused its efforts on researching eligibility not only for ED patients, but also for patients across the system. It invested in outside personnel (who could be contacted after hours, when needed) to support its clinical and financial staff in determining patients' eligibility for financial assistance programs, and restructured its eligibility program to emphasize face-to-face meetings with every self-pay patient. Patient interviews typically uncover information that steers personnel toward investigating specific financial assistance programs (for example, Medicaid for the single mother who has been unable to navigate the tortuous Medicaid application process, or SSDI benefits for an elderly man who is unaware of benefits that cover treatment for his chronic condition).
Once potential coverage is identified, financial assistance eligibility personnel work as patient advocates, completing forms, forwarding medical records to the appropriate agencies, and answering patients' questions. Rather than expecting patients who have no expertise in working with these complex programs to complete applications for assistance on their own, Ochsner provides the necessary support and services to complete this process. The result is a win-win situation in which patients are relieved of the burden of dealing with bureaucratic benefits programs and the hospital receives higher levels of reimbursement more quickly.
Financial eligibility personnel also maintain a list of the self-pay patients interviewed during the past 24 hours as well as information regarding which financial assistance programs may benefit each patient. This information then is passed on to the hospital's finance department, which accrues whatever benefits are available onto the hospital's accounts. Weekly and monthly compilation reports track the impact of each case on the hospital's financial status.
Ochsner's eligibility services personnel also keep caregivers apprised of potential programs and coverage options that are being explored. This not only equips clinical staff with valuable information, but also helps reassure them that their patients won't be overwhelmed with medical bills upon discharge. In addition, caregivers are alerted to any restrictions that might compromise coverage (for example, medical necessity rules that govern Medicare or Medicaid payment).
The impact of Ochsner's changes to its financial eligibility assistance program has been significant. The hospital has experienced not only a 22 percent increase in eligibility approvals, but also a roughly 17 percent increase in the number of accounts in the "pending" stage of benefits programs. These efforts have brought significantly more revenue into the door, netting increased cash on the bottom line and easily offsetting the cost of hiring outside personnel.
Additionally, Ochsner's revitalized approach to helping self-pay patients determine their eligibility for financial assistance programs sends a consistent message to patients and to the hospital's community, which also seeks to work with patients in helping them cover the cost of their care. Within this context, patients welcome the opportunity to work with eligibility personnel to identify previously unknown financial resources and to take responsibility for their financial obligations for the care and services they receive. Patients also appreciate the hospital's willingness to work with them in finding resources that will help pay for their care, now and in the future.
Ochsner's partnership with outside eligibility services personnel also has provided the hospital with access to comprehensive resources and hands-on assistance during times of crisis and extreme overflow. For example, in the aftermath of Hurricane Katrina, when 200,000 New Orleans evacuees took refuge in Baton Rouge, doubling the size of the city overnight and overwhelming its healthcare system, Ochsner's ED was deluged with new patients from area shelters for weeks after the initial rescue of evacuees. Even in this chaotic environment, Ochsner was able to minimize its concerns regarding how to determine financial assistance eligibility for these patients, since backup and overflow personnel were already on hand to assist the hospital.
Is Your Eligibility Program in Need of an Overhaul?
Leaders at Ochsner believe the hospital's success in restructuring its financial assistance eligibility program can serve as a blueprint for other hospitals that are re-evaluating the strength of their financial assistance eligibility processes.
If your organization is considering restructuring its eligibility services to better meet the needs of patients and the organization as a whole, consider the following.
Conduct a "gap analysis" to effectively determine your organization's needs. For example, after Ochsner experienced a significant increase in the number of self-pay patients coming through its ED, the hospital determined that it needed eligibility experts who were well versed in financial assistance programs
and eligibility requirements, and timely reporting-not only in the ED, but throughout the organization-and who were willing to come in after hours, when needed.
Communicate with other facilities that have faced similar problems to uncover what solutions have worked-or not worked-for them. For example, Ochsner spoke with representatives from an Atlanta hospital regarding steps the hospital took in revamping its financial assistance eligibility program, and considered partnering with a consultant based on this hospital's experience.
Recognize that identifying coverage for the underinsured and uninsured requires a special skill set. Staying current with changing rules and guidelines is a Sisyphean task. Eligibility personnel should be committed to ongoing education and training, and should demonstrate expertise in lesser known and local programs.
If your organization is considering outsourcing its eligibility services, Ochsner offers these recommendations.
Make sure your organization has in place the appropriate level of eligibility expertise when and where it is needed. For example, Ochsner Medical Center determined that, for investment in eligibility personnel to be effective, these personnel would need to be skilled in working not only with ED patients, but also with patients throughout the organization.
Assess the availability of reporting and analytics of the eligibility services provider. Facilities need snapshot views of the status of individual cases, but also require high-level reports to provide visibility into the initiative's impact on the revenue stream. At Ochsner, weekly and monthly compilation reports tracking the results of the initiative, as well as a list of the self-pay patients interviewed during the previous 24-hour period and the financial assistance programs that may benefit each patient, keep senior leaders informed of the progress being made and provide valuable information to patient financial services staff and caregivers as well.
Take time to make sure the chemistry is right. Eligibility specialists should be part of a team that encompasses patients, providers, and billing staff, and should respect and empathize with the priorities of each. As such, it is important to make sure the personnel who are chosen are a good fit with key staff throughout the organization.
Don Woodward is former director of patient financial services, Ochsner Medical Center, Baton Rouge, La. Queries may be directed to firstname.lastname@example.org
Publication Date: Monday, February 01, 2010