Specialist: Reimbursement opportunity being missed
Disability program has 'untapped potential'
Something that puzzles Patti Thrailkill, who spent more than 20 years working with the federal disability program, is why there isn't more energy at hospitals spent trying to get disability benefits for patients.
Several misconceptions about the program are preventing access managers and other personnel from taking advantage of "the untapped potential of Medicaid" in obtaining coverage, suggests Thrailkill, now director of governmental affairs for MedAssist, an eligibility services vendor.
The self-pay population is particularly well served by the federal disability program, she points out, because Medicaid is one of the benefits that comes with it.
"There are misunderstandings about [the federal disability program] and it is detailed, but accessing it is not that difficult," she says. "Either the eligibility services vendor, if you outsource, will pick up the load, or the Social Security Administration [SSA] will take over once you get [the application] in motion."
While the federal government controls Medicaid and contributes most of the money, states vary in their funding, she notes. "As Medicaid programs grow, the number of those that [states] can afford to fund shrinks.
"Medicaid dollars are spread across fewer and fewer categories," Thrailkill says, "but one category that is always funded is federal disability." It is one of five or six mandatory Medicaid programs, she adds.
An area that states can fund or not, on the other hand, is retroactivity, she says. "The date of the application is used to start Medicaid, so if you don't make application at the day of admission, it won't cover the first day, which is the most expensive but if it's retroactive, it is covered."
It is important, Thrailkill says, to make sure that staff understand the distinctions between the Supplemental Security Income (SSI) program and the Social Security Disability (SSD) program, both of which are administered by the SSA. She explains those differences as follows.
SSI benefits, she explains, are targeted to low-income aged, blind, disabled adults and some children and provide monthly income for eligible individuals. The money for SSI programs comes from general taxes, a combination of federal and state dollars. Medicaid is the health insurance program associated with SSI disability benefits. This insurance typically is available as of the date of application/service.
SSD benefit programs are for people who have worked and paid enough FICA withholding taxes to qualify. These tax dollars are collected and managed by the federal government. They are not based on financial limitations, but strictly on having accumulated benefits through paying taxes and confirmation of disability. Medicare is the health insurance program associated with SSD disability benefits, which are typically available two years after the onset of a medical condition.
Thrailkill, who frequently speaks to hospital groups that include access managers, says the extent to which her listeners comprehend the programs varies widely. "I watch the audience to see if I get a [reaction indicating] they don't understand."
Five common misconceptions, along with Thrailkill's clarifications, are listed below.
- Misconception No. 1: The SSA makes special arrangements with some companies, which creates exclusivity or preferences in working claims.This is absolutely not true, she says. "SSA is an agent of the federal government and all federal agencies are 'equal opportunity providers.' Unilateral agreements are not legal for any federal agency, so no preferred agreement can be made with any company to grant faster, better, or easier access to SSI or SSD benefits for the clients they represent."
- Misconception No. 2: All disability applications can be made on-line.Only SSD not SSI applications can be made on-line at this time, Thrailkill says. Eligibility for SSD benefits is based on taxes paid on an individual's wages, she adds, and his or her eligibility is checked electronically using a Social Security number. SSD applications can be done on-line because eligibility is easily verifiable, Thrailkill says. Determining eligibility for SSI, on the other hand, is a manual process that involves collecting information about an individual's current income and resources, she explains, and "the potential for fraudulent reporting of income and resources is significant."
- Misconception No. 3: Patients must be represented by an attorney to get benefits.Benefits are granted based on objective evidence submitted to the SSA and the state Disability Determination Services (DDS) office, Thrailkill says, and attorneys are not a necessary component of the process, nor are patients penalized if they do not have an attorney. The process, she adds, works like this: The SSA determines technical eligibility based on taxes paid on wages and/or income and resource levels. Once the SSA has decided the person is technically eligible for SSI, SSD, or both, the application is sent to the DDS office.At that point, DDS determines "medical eligibility" based on medical records, age, education, and work experience/capability.One of the questions she hears most frequently, Thrailkill says, is: "Why are some patients with severe medical problems denied and others who do not have such bad conditions allowed?" The answer, she adds, usually is that those individuals do not meet the "technical requirements" for SSI or SSD.
- Misconception No. 4: It takes two years to get a disability decision.In actuality, Thrailkill says, initial and reconsideration decisions which are made by the state DDS take an average of 120 days, although that time can be shortened dramatically with assistance from eligibility services vendors. The five decision levels in the disability application process are 1) initial decision; 2) reconsideration decision; 3) administrative law judge (ALJ) decision; 4) appeals council decision; and 5) federal court decision (usually a class action). The national average for decisions made by administrative law judges is two years, however, and appeals council and federal court decisions average more than two years, Thrailkill adds.
- Misconception No. 5: Administrative Law Judges make all of the allowances decisions.While, as mentioned before, ALJ decisions do take an average of two years, the upside, Thrailkill points out, is that those outcomes account for 29% of all allowance decisions not 100%. DDS offices within each state make 71% of the allowance decisions.One reason for the misconception that all allowances for the disability program come via ALJs, she notes, is that most hospital CEOs are hyperaware of the claims awaiting disposition by the ALJs because they are high-dollar cases."The backlog is as high as three years in some areas," Thrailkill says. "These [claims] have been denied twice and they're old. The balance keeps growing."The SSA is very aware of the need to speed up the application process for disability claims, and is taking action in that regard, she adds. The agency is inundated, Thrailkill says, because it manages five other programs in addition to SSI and SSD.Among other efforts to move the workload along, the SSA is trying to become paperless, she notes, and is starting with the disability program because it is the most labor-intensive.
Thrailkill urges access managers to pursue disability coverage for patients who might qualify. "In order to initiate a claim, all you have to do is make a phone call, so there is no reason not to apply.
"The more you help the patient, the quicker the process will move along," she says, advising that access staff take these steps to facilitate the claim:
- Electronically transfer medical records as often as possible.
- Provide upfront medical records on the most severely medically compromised patients.
- Provide medical records on long-term inpatients.
"Get a process in place to target these people at admission," Thrailkill advises. "It is worth it in terms of dollars."
(Editor's note: Patti Thrailkill can be reached at email@example.com.)