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Surge in underinsured, self-pay? Use these tips
The utilization of services by self-pay patients has increased by 6.9% over the last fiscal year at St. Joseph's Hospital and Candler Hospital, both in Savannah, GA, says Susan M. Younggreen, director of patient financial services.
As a result, Younggreen says that members of the patient access staff recently have become more proactive about informing patients on how they can receive help with their bills.
Registrars refer patients to the hospital's financial counselors and/or the Medicaid eligibility vendor, inform them of prompt-pay and self-pay discounts, and provide financial assistance applications with instructions, says Younggreen. "This is really not a new role for the patient registrars," says Younggreen. "They are just providing more information than before, and are doing so without being asked."
Access staff have done point-of-service collections for inpatients, same-day-surgery, imaging, and ED patients for about four years, says Younggreen, but over the past two years, collections have been slowly decreasing. "We are currently in the process of implementing an initiative to increase collections," she reports. "We have identified the most successful collectors and are having them coach the others."
The coaches do some role-playing, which gets less experienced staff more comfortable with collecting from patients, says Younggreen. "We are emphasizing that customer service and respect for the patient is more important than collections," she adds. "This was just initiated at the beginning of the year. We have no results yet, but we are optimistic."
While the hospital's financial counselors are a part of patient accounts, these individuals work closely with the registrars, notes Younggreen. In November 2010, the hospital revised its financial assistance process, which included a 65% self-pay discount for uninsured patients, she adds. "We increased the visibility of our financial assistance program on our web site, as well," says Younggreen.
Patient satisfaction is always a priority, says Younggreen, so staff members attempt to address any concerns the patient has about his or her bill as soon as possible in the patient experience. "This may be at pre-registration time or the day of the visit," she says.
The coaches offer refresher sessions to the registrars, which review the different methods of financial assistance, says Younggreen. "We provided scripting for the registrars to use when offering the financial assistance application," she adds. "The scripting was designed to put the patient at ease. We offer assistance in a way that is not embarrassing."
Major changes made
The hospital's financial assistance program was already "fairly liberal," according to Younggreen.
"We use a sliding-fee scale. Anyone applying who makes 250% or less of the poverty guidelines qualifies for a 100% write-off of their balance, even including the deductibles and copayments after insurance," she reports.
A person making up to 500% of the poverty guidelines could qualify for a percentage discount ranging from 15% to 90% of the balance, depending upon income and the size of the bill, adds Younggreen.
The sliding-fee scale also changed, so the least amount of discount a patient without insurance now receives is 65%, says Younggreen. "In November 2010, our charity write-offs were 21% over budget, but we were still running 4% less than last year," she reports. "The full impact of the change has yet to be determined."
New access roles
Lee Anna Mull, patient access manager at Mission Hospitals in Asheville, NC, says, "We have seen a steady increase in self-pay/underinsured patients in the past two years." Managers recently created a financial counselor position to focus solely on the inpatient "self-pay" patient, due to greater volumes of these patients.
"Currently, we have someone on site that gets a report each day on the self-pay patients," says Mull. Staff screen these patients to see if they have insurance that was possibly not entered into the system, or if a patient might be eligible for vocational rehabilitation or Medicaid, explains Mull. "If the patient is a true self-pay, a financial counselor will visit the patient's room and complete a charity care application," says Mull.
In the emergency department, financial counselors meet with self-pay and underinsured patients at the time of their visit, adds Mull. "They meet with any patient who needs financial assistance or has an outstanding balance," she says. "We are hoping to reduce the amount of uncollected dollars in A/R."
"We have many options for self-pay patients expecting a large balance," says Mull. "We are able to offer the patient a prompt-pay discount. We can assist them with an affordable, interest-free monthly payment plan."
The patient can apply for a charity care discount based on federal poverty guidelines, household size, and income. Staff offer a catastrophic discount for balances of $10,000 or greater, if the patient is incurring large hospital bills.
"Financial counselors actively pursue collection efforts on bad debt accounts that have been placed with a collection agency," says Mull. "Accounts are placed with an agency, if all attempts to work with the patient have been exhausted."
These steps are taken before an account goes to collection, says Mull:
1. The patient receives a series of monthly billing statements requesting payment in full.
"Those with insurance do not get a statement until after their insurance has paid," Mull notes.
2. Patients receive a past-due statement if they do not respond.
A collection representative might place a call to the patient and offer a payment arrangement or a discount for payment in full, says Mull. "They also take financial assistance applications for charity care consideration over the phone with the patient," she says.
3. Patients receive a final notice statement prior to their account being placed with a collection agency.
"Ample time is given for the patient to settle their account balance before moving it to an agency," says Mull.
Don't let staff settle for misleading copay data
If some particularly dismal copay collection data came to your attention, chances are you'd want to scrutinize it carefully before presenting this to senior leaders.
At Cincinnati (OH) Children's Hospital Medical Center, the patient access and outpatient preregistration department is working with the hospital's Information Services (IS) department to automate its co-pay auditing processes, says Michelle C. Gray, MHA, director. "Technology, in general, has helped us work smarter," says Gray. "We are constantly stretching our imagination and working collaboratively with our IS department to get the best results from our systems."
With the new co-pay auditing process, Gray expects to see increased copay collection rates and the ability to provide more accurate co-pay collection rates to senior level executives.
Although outpatient areas are considered to be centralized registration, there also are some decentralized registration areas, notes Gray. "In the centralized areas, we have always audited copays," she says.
In 2010, one of the decentralized areas presented its copay percentage during a presentation to senior leadership. "It wasn't very high, and so, our new CEO/president wasn't very happy with that. They knew we could do better," Gray recalls. "What came out of this meeting was an intense, hospitalwide focus on copay collection."
The presentation "kind of lit a fire under all of us," says Gray. "Before, it was an area that really wasn't discussed. It became a topic that was on everybody's top list to look at and do a better job at."
Patient access leaders were skeptical about the accuracy of the department's copay data, because it seemed low compared to what was being collected in centralized registration areas, Gray reports. Those areas audited copays daily, she says.
"Our numbers weren't close to theirs at all. We started to question, just how accurate is this data?" says Gray. "Our copay collection rate was being rolled into everyone else's."
Gray and her colleagues set out to work with the department that generated the original report to develop a more accurate copay report to distribute to senior level executives. An auditing tool was developed that every registration department could use, Gray says.