New data gives patient access leaders a compelling reason to invest in tools, training, and revamped processes to convert self-pay patients to some type of coverage.
Nearly half of the 32.3 million nonelderly people in the United States who didn’t have health insurance at the beginning of this year are eligible for Medicaid or subsidized coverage through an Affordable Care Act (ACA) Marketplace, according to an October 2015 analysis by Kaiser Family Foundation.
Converting self-pay patients to some type of coverage is a top priority at Roseville, CA-based Sutter Health. “We utilize a third-party company that reviews all our self-pay accounts for other coverage eligibility,” reports Becky J. Peters, system director of Patient Access Services at Sutter’s Shared Services Center.
Employees of the healthcare provider screen emergency department patients and inpatients presenting as self-pay. “They also receive a download of outpatient self-pay accounts that go through their scrubbing for potential eligibility,” says Peters. “They have a 93% conversion rate for eligible accounts.”
The percentage of uninsured patients who are eligible for Medicaid or subsidized ACA coverage ranges from 35% in Nebraska and Texas to 75% in West Virginia, the Kaiser Family Foundation analysis indicated.
Five states make up about 40% of the uninsured population that could receive Medicaid or subsidized private coverage under the ACA. Those states, and the number of uninsured who are eligible for assistance, are California, 2.1 million; Texas, 1.5 million; Florida, 1.1 million; New York, 865,000; and Pennsylvania, 656,000.
Patti Consolver, FHAM, CHAM, senior director of patient access at Texas Health Resources in Arlington, TX, says, “About 30% of our patients that historically were in the uninsured bucket now have some sort of coverage.”
Even if patients obtain coverage under the ACA, however, many face high out-of-pocket costs. “We still have the problem of people following through with paying their portion of the subsidies on ACA,” says Consolver.
Texas Health’s patient access department partners with an eligibility vendor to refer patients who want to know more about the options on the Exchange market and how to apply. “Our process to convert self-pays to coverage is to screen these patients, either in-house, or we refer them to our eligibility vendor to follow up,” says Consolver. The department tracks the number of patients who were previously uninsured or eligible for the hospital’s charity assistance program and now have coverage.
“Of the self-pay population that we screen during ACA open enrollment, we convert 51% to a Medicaid program and counsel an additional 14% on the ACA enrollment,” says Consolver. These numbers leave about 35% of the screened population ineligible.
“Of course, this only includes the patients screened for eligibility,” Consolver notes. Many patients never respond to attempts to contact and screen them. “Also, the population outside of the income limits [for Medicaid eligibility] is greater than other states, given that Medicaid has not expanded here,” says Consolver.
Some of the nonelderly who are uninsured fall into a gap: They earn too much to be eligible for Medicaid, but they don’t earn enough to be eligible for financial assistance through an ACA Marketplace. The number falling into the gap is 10%, or 3.1 million.
The gap exists in 20 states that elected not to expand Medicaid. Among those states, the ones with the largest number of people with the coverage gap are Texas, 766,000; Florida, 567,000; Georgia: 305,000; and North Carolina, 244,000.
The report, New estimates of eligibility for ACA coverage among the uninsured, is based on data from the 2015 Current Population Survey Annual Social and Economic Supplement and other sources. [Editor’s Note: The December issue of Hospital Access Management will report on successful processes used by access departments to convert self-pay patients to some type of coverage.]