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Patient access often is tasked with telling people bad news: What insurance will not cover, the amount of their deductible, or why an appointment needs rescheduling.
However, there is one notable case in which patient access have something to say that surely will make the person’s day. The patient who comes in as self-pay might find out that, in fact, he or she is eligible for Medicaid. This is especially common in states that have expanded Medicaid through the Affordable Care Act. “Our ED registration team received extensive training on Virginia’s Medicaid expansion program,” reports Sonya M. Meade-Settles, BSHM, CHAM, director of patient access at Chesapeake (VA) Regional Healthcare.
Recently, an uninsured patient came to the ED in need of medical care. The registrar conducted a financial screening. Next, the registrar used an insurance verification tool to conduct a generic Medicaid search, which yielded some surprising news: active coverage for the patient under the recent Medicaid expansion. “The patient was not aware of this coverage,” Meade-Settles says.
Initially, the patient declined some of the diagnostic tests the physician recommended. “However, the good news changed his decision,” Meade-Settles reports. “The patient moved forward with the proposed treatment.”
The registrar’s efforts meant that the patient received needed medical care and that the hospital could receive reimbursement. “This was a job well done,” Meade-Settles adds.
At Boston Medical Center, “our payer mix is largely government payers. Medicaid and Medicaid third-party liability are among our biggest payers,” reports Joseph Ianelli, MSW, MBA, senior director of patient access.
To avoid coverage lapses for this patient population, patient access employees take the following steps:
• Staff are proactive in identifying people who might be eligible for Medicaid. It is unrealistic to assume everyone has coverage as required by the Affordable Care Act. “Everybody is supposed to have insurance. But we know there are a lot of people who weren’t able to follow through for a number of reasons,” Ianelli acknowledges.
Financial counseling staff do not wait for people to arrive for services before checking into this. They look at who is scheduled with no insurance. Then, staff contact those patients. “If we cannot reach the patient, we meet them at their appointment,” Ianelli explains.
Some financial counselors work with specific clinical services, such as the cancer center, primary care, infectious disease, or orthopedics. “That creates a nice partnership with the practice. They know who their contact is in financial counseling,” Ianelli says.
• Staff take responsibility to prevent lapses in coverage or re-establish coverage that has lapsed. “The Medicaid population comes on and off coverage,” Ianelli reports. “For this reason, financial counselors need their finger on the pulse.”
Staff need to know to catch patients in the moment when they are accessing care. Certain patients cannot keep up with the Medicaid redetermination process. When coverage is about to lapse, Medicaid sends a letter. “But patients aren’t always in a position to read and respond,” Ianelli says.
Other patients are in danger of losing their coverage because of chronic illness, such as cystic fibrosis or cancer, that results in job loss. “That is a little tougher to identify. But it may be possible to leverage registration systems to show who is working and who isn’t,” Ianelli offers.
Sometimes, there is no mystery at all because the information comes directly from the patient. A patient may tell a registrar, nurse, or doctor that he or she is about to lose Medicaid coverage. “There should then be an all-out effort to get the patient connected with financial counseling,” Ianelli advises.
Certain states operate more restricted Medicaid programs. In those states, fewer patients will meet the criteria. “But there still should be a range of programs patients can access that we can help them with,” says Ianelli, noting this ranges from charity care to medication assistance plans. “All of that falls under the financial counseling umbrella.”
It would be a different story if somebody had a lot of resources, was not sick, and just happened to be on Medicaid. “But sometimes people are really compromised. They are truly sick and have other social determinants of health working against them,” Ianelli says.
The best approach is to arrange a meeting for whenever the patient is coming in next. “Financial counselors really have to be available and be accessible as much as possible,” Ianelli stresses.
Once Medicaid coverage is terminated and the patient has to do something to re-activate it, education and advice is not enough. “Advising patients to go home and re-establish coverage is honestly not going to work,” Ianelli warns. Instead, financial counselors do what they can to fix it right away.
“They can call Medicaid offices or look in state systems to determine what action steps a patient needs,” Ianelli suggests. Establishing access to Medicaid, or re-starting coverage that has lapsed, “is really a lifeline for many sick patients,” Ianelli says. “It’s so important.”