Is a patient eligible for financial help? - The sooner you find out, the better

There may be little motivation to cooperate

The patient standing in front of you, or on the receiving end of a phone call from an access staff member, may be confronted with a balance that he or she cannot possibly pay. What happens next?

"With the onset of higher-deductible insurance plans and health reimbursement account-type insurance plans, patients are finding that they owe higher amounts out of pocket," says Jeff Brossard, CHAM, patient access manager at St. John's Hospital in Springfield, MO. "Often, patients are unable to pay these out-of-pocket amounts due. In more recent months, this trend has become increasingly apparent."

For this reason, your process for determining if patients are eligible for charity or public programs has become increasingly important. Patient access' immediate concern is the ability to make contact with these patients prior to their visit. "From an outpatient perspective, it is better to contact the patient as early in the process as possible, preferably prior to the date of service," says Brossard. "This can pose additional problems, though, as some people will cancel their test or procedure when they find out about the high co-payment or deductible owed."

For inpatient services, St. John's Hospital contracts with an outside vendor for Medicaid eligibility screening. "If the patient does not qualify for Medicaid, they are then referred to our in-house financial counselors," says Brossard. "In cases where the patient has been discharged prior to the Medicaid screening completion, additional contact can be difficult."

Many negative impacts

Regarding eligibility screening, "It is better for both the health care facility and the patient to initiate this process as early possible," says Brossard. "The negative impact of not initiating this process early is the simple fact that facilities can miss the opportunity to help a patient obtain assistance. With this, the outstanding balance may go unpaid. Expenses associated with collecting will increase."

Holly Hiryak, RN, CHAM, director of hospital admissions and access services at University Hospital of Arkansas in Little Rock, says, "If we miss the opportunity at the very first encounter, our work becomes more difficult, especially if the patient received the services they were seeking. They have little motivation to cooperate."

If a patient's self-pay status isn't identified early in the process, "the impact is twofold," says Catherine M. Pallozzi, CHAM, CCS, director of patient access at Albany (NY) Medical Center Hospital.

"First, the need to have the discussion the day before a procedure causes undue apprehension for the patient and family, not to mention the staff member," says Pallozzi. "Second, obviously, the facility is in jeopardy of not being paid, especially for those urgent procedures that could have had a bit more notice provided to patient access."

One challenge is ensuring that patient access is notified of the self-pay status for patients with scheduled ancillary services. "We do not have a centralized scheduling system, which means patient access relies on the ancillary department to alert us of a self-pay patient," says Pallozzi.

Pallozzi says that "the name of the game is education and communication. With our system limitation, it is most important that the ancillary department managers are well versed in making the referral to our patient assistance unit. If we find a circumstance where communication was lacking, it provides the opportunity to educate the respective department or physician's office."

Another challenge involves balancing the patient care aspect with the financial aspect. "We never delay an urgent or emergent procedure, but we do postpone those services deemed elective," says Pallozzi. "If there is any question regarding the status of urgency, our medical director will assist in a conversation with the attending physician."

Albany Medical Center has a self-pay policy and procedure that outlines the expectations and escalation process of a case that may be in question regarding its status of urgency. The policy provides for the escalation process to include the medical director if there is a need for a physician-to-physician discussion for the patient to proceed. "It is a good source document for education," says Pallozzi.

Staff must know the basics

Brossard says that his access department has made a major push in education, to address the increase in self-pay patients. "Frontline co-workers are more often required to wear dual hats, so to speak," he says. "Not only do they need to be well versed in the insurance industry, but they must also understand the basics of financial counseling."

At St. John's, patient access staff use scripting to ensure that a consistent message is provided. New co-workers receive two weeks of classroom training covering all aspects of patient access. Several sessions on point-of-service collections, determining patient financial responsibility, and scripting for financial counseling referrals are included in this training. Additionally, the department offers ongoing refresher training as well as annual competency training on all of these topics.

"The role of the financial counselor is expanding. Many health care facilities are creating additional financial counselor roles to accommodate the influx," says Brossard. "Also, depending on the cost of a patient bill, it is becoming more commonplace to provide assistance in the form of paying COBRA or Medicaid premiums, to ensure there is no lapse in coverage."

Hiryak says that one of her current challenges is to train staff to understand the various categories of Medicaid in the state.

"The process of determining the appropriate category and casework requires a tremendous amount of education," says Hiryak. "We estimate that it takes at least two years to train a caseworker to the point that second-party reviews are no longer required. It is a bit less for the applications specialists, but they are always in learning mode as policy changes."

To address this, a series of questions was developed to screen out individuals who do not qualify for assistance. Then, the applications specialist determines the potential category and takes the appropriate application.

Once the application is completed and registered with the state Medicaid program, the applications are sent to the Medicaid caseworker's department for completion. 

"We have two staff designated for verification and home visits if needed and a runner, as we often have to hand-deliver some cases to our county offices," says Hiryak. "We have nine caseworkers, with three off-site and the remainder hospital-based." Once they complete the case, it is sent to one of the hospital's Department of Health and Human Services partners, who then keys the information into the database.

"We have actually aligned our applications specialist with the admissions/registration department," says Hiryak. "This enhances the work flow processes and prevents multiple unnecessary contacts with the patient." All patients classified as self-pay are picked up by the applications specialist. "They screen and/or apply for the patients. If any additional paperwork is required, they can get that completed while they are at the bedside," says Hiryak.

[For more information, contact:

• Jeff Brossard, CHAM, Patient Access Manager, St. John's Hospital, 1235 E. Cherokee, Springfield, MO 65804. Phone: (417) 820-9089. Fax: (417) 820-4880. E-mail:

• Holly Hiryak, MNSc, RN, CHAM, Director, Hospital Admissions/Access Services, University of Arkansas Medical Sciences, 4301 W. Markham, Little Rock, AR 72205. Phone: (501) 686-8170. Fax: (501) 603-1243. E-mail:

• Catherine M. Pallozzi, CHAM, CCS, Director, Patient Access, Albany (NY) Medical Center Hospital. Phone: (518) 262-3644. Fax: (518) 262-8206. E-mail:]