With revamped processes, collect millions in retroactive payments

Patient accounts are 'never a lost cause'

Would you consider one-year-old uncollected account with a large outstanding balance to be a lost cause that ultimately will need to be written off?

"Don't be so sure," says Nikki Mahieu, manager of registration services at Trinity Regional Health System in Rock Island, IL.

While retroactive coverage is typically in effect for 90 days prior to the date of service, Mahieu notes that there are certain exceptions for disabled patients. "We will go back to when they were originally diagnosed with a certain illness," she says. "We have had a lot of success with retroactive disability payments with dates of service up to a year ago."

Previously, a vendor reviewed patient accounts with outstanding balances at Trinity Regional and attempted to submit updated information so patients could obtain coverage if they were eligible for assistance. "We found that it wasn't as successful as we thought it was," says Mahieu. "The previous vendor was not very diligent in following up with patients."

In contrast, members of the access staff take extra time to visit the patient while he or she is still in the hospital and show compassion for the patient's overall situation, not just their lack of insurance coverage or unfavorable financial situation, Mahieu explains.

To obtain better results, the patient access department hired a Medicaid specialist who focuses only on disability patients, with 300 accounts reviewed to date. "It has been very surprising. We have been able to convert a lot of patients which we thought were a lost cause," says Mahieu.

Unfortunately, some patients give up when they hit a roadblock in the application processor when they fall just below the criteria for disability coverage, says Mahieu. "We try to keep in contact with patients when they return, or if their health or financial status changes, so we can continue to work their case," she explains.

The Medicaid specialist moves applications through the system faster than access staff would be able to, because she knows exactly what documentation is needed. "Instead of having to wait for one approval and then submitting another, she bundles it all together and sends it on," says Mahieu.

Charity still available

A couple of patient accounts dating back to 2006 are being appealed for disability coverage, adds Mahieu.

"We are hopeful to get these patients on active disability," she says. "Sometimes it is a long shot, but never a lost cause."

Over a six-month period, Mahieu was able to convert $400,000 in account balances to disability coverage that originally had gone to charity. In these cases, the patient came back for a return visit, and patient access staff took the opportunity to review their previous account balances. "We found they had been seen previously for the same issue. So we were able to retroact their disability coverage for dates in 2009 and 2010," says Mahieu.

This disability coverage means that the hospital's charity resources can be saved for patients who do not qualify for any funding source whatsoever, she notes.

Just recently, patient access staff have started looking at self-pay accounts with small balances, which can sometimes be overlooked, says Mahieu. "We have identified approximately $2 million in gross charges that may be potential candidates for Medicaid and disability," she says.

About 6% of self-pay patients seen at Vanderbilt University Hospital in Nashville are approved for Supplemental Security Income (SSI) or disability, says Marsha Kedigh, RN, MSM, director of admitting/emergency department registration/discharge station/insurance management, for which the hospital receives retroactive reimbursement. Of the last 62 cases approved for SSI, the hospital received $733,925.32 in revenue, she reports.

9.5% return on retro reimbursement

Currently, the hospital is obtaining a 9.5% return on retroactive reimbursement for the gross charges of these patients.

"Financial counselors follow every self-pay admission," says Kedigh. "While Medicaid approval will reimburse back to the date the patient applied, SSI reimbursement starts the first of the month after approval."

Stacy Calvaruso, assistant vice president of patient management at Ochsner Health System in New Orleans, says there has been a noticeable increase in self-pay patients, primarily entering through the ED.

"We identified a need to identify these patients as early as possible and to proactively communicate with them regarding their financial obligations," Calvaruso says.

The department implemented a full pre-service center, a no-interest patient loan program, and a propensity-to-pay program. "We have focused on enhanced communication efforts with patients about their prior balances, in conjunction with that day's obligation," adds Calvaruso.

In addition, the hospital contracted with an outside Medicaid eligibility vendor who meets with patients in the major entry areas such as the ED. "We found that we were able to locate many patients who actually had Medicaid coverage," says Calvaruso. "They just failed to contact us and share that information."

Patients typically won't provide this information for a single visit, if they think that they will not return for future services, explains Calvaruso.

"We also took all of our Medicare patients with no secondary payers and ran eligibility checks on them," she says.

About 14% of those patients already had Medicaid coverage, with an additional 16% eligible for Medicaid or a charity care program. "We do attempt to obtain retroactive coverage and have seen positive results," says Calvaruso. "In this past six months, our program has qualified over 700 individuals for Medicaid coverage." (See related story on self-pay patients, at right.)


For more information on obtaining retroactive coverage for patients, contact:

Marsha Kedigh, RN, BS, MSM, Director, Admitting/ED Registration/Discharge Station/Insurance Management, Vanderbilt University Hospital, Nashville, TN. Phone: (615) 818-9620. Fax: (615) 343-5922. E-mail: marsha.kedigh@Vanderbilt.edu.

Nikki Mahieu, Manager of Registration Services, Trinity Regional Health System, Rock Island, IL. Phone: (309) 779-2250. Fax: (309) 779-2209. E-mail: MahieuNA@ihs.org.

Sherri Pitkin, Associate Director, Patient Access Management, University of Iowa Hospitals and Clinics, Iowa City, IA. Phone: (319) 384-2323. E-mail: sherri-pitkin@uiowa.edu.