Recently, an exasperated parent brought a shoe box full of bills to Ann & Robert H. Lurie Children’s Hospital of Chicago. Some hospital bills were in the stack, but there were also paper bills from multiple other providers and facilities. “The financial counselor separated, organized, and reviewed each bill,” says Robin Speaks, MSHSA, CHAM, quality manager for the revenue cycle.
It turned out some of the bills were duplicates. Others were for various amounts, small and large. The parent left much calmer, with a solid plan in place. “In the end, the patient was eligible to apply for state programs to assist with meeting their financial obligations,” Speaks says. For patients facing a stack of hospital bills, there is a new kind of expert ready to help. Highly trained employees now “financially navigate” on behalf of patients.
At Lurie Children’s, one financial navigator helps patients, but more are in training. “We are strengthening the department to eventually develop a team of financial navigators,” Speaks says. Here are some of the patients who are receiving much-needed help:
• People who have never had commercial insurance. Many in this group have no idea how insurance works, or even what a copay is. Sometimes, an employer provided no information. Other times, there was information, but the employee did not understand it. “We take our time to explain and give examples of how their plan works,” Speaks reports. “Patients are able to make better healthcare financial decisions.”
• Patients who switched from the traditional Medicaid program to the state-mandated Medicaid Managed Care Organization (MCO) program. After this change, the financial navigator dealt with many people who were “confused or exasperated,” Speaks says. First, the navigator explained the reason for the change and the family’s responsibility (i.e., selecting the appropriate MCO for the child and family). “We assisted in obtaining referrals and prior authorizations for services, which these patients never had to do before,” Speaks notes.
Many people with a Healthcare and Family Services (HFS) medical card suddenly were required to enroll in HealthChoice Illinois, the Medicaid managed care program. HFS mailed letters to families informing them of this change. Some never received the letter; others misplaced it or ignored it. “Countless families were going to be affected by this change,” Speaks explains. The hospital took a proactive approach by educating all revenue cycle staff. Not surprisingly, the change did not go smoothly. “There were innumerable complications with the state rolling out the program and recipients trying to reach out to the state-provided vendors,” Speaks recalls.
• Families who are overwhelmed by the sheer volume of bills, statements, and Explanation of Benefits they receive. Phone calls and mail comes from the hospital, various physicians, and the insurance company. A surprising number of people simply ignore it all. “Once the financial navigator gets involved, it becomes clear that the patient is actually eligible for a state program,” Speaks observes. This can help even when the bills are from other hospitals or providers. “Other facilities acknowledged the need to apply old balances to charity care,” Speaks says.
The financial navigator assures the patients they are not alone. Navigators help patients understand their commercial or state coverage and benefits, including workman’s compensation or other third-party liabilities. They help patients sort out multiple bills and understand it all. Navigators inform patients if their coverage is in network or out of network and whether there are requirements for prior authorization or referrals. Also, navigators help patients complete financial assistance applications, enroll in state programs, or set up payment plans.
All financial navigators have at least two years’ experience in patient registration, and have some accounting or banking experience. They also have solid knowledge of ICD-10 coding, medical terminology, third-party billing and collections, and commercial and managed care industry requirements. Perhaps most importantly, anyone doing this job “must also have a genuine ‘heart’ for people, to help and advocate when necessary,” Speaks adds. Providing financial navigation training to staff at hospitals and cancer centers is more than just the right thing to do. It turns out it can decrease patients’ out-of-pocket expenditures significantly. (.)
“We have long been interested in the financial toxicity associated with cancer care and the long-term consequences,” says Todd Yezefski, MD, a senior fellow at the Fred Hutchinson Cancer Research Center in Seattle. Of 11,186 new patients with cancer seen at four hospitals between 2012 and 2016, 32% qualified for financial assistance. “The sheer magnitude of the financial benefits for both patients and hospitals was the most surprising finding,” Yezefski says. The four hospitals avoided write-offs and saved on charity care by an average of $2.1 million a year. “There is a huge return on investment for the hospitals,” Yezefski adds.
Patients accessed tens of thousands of dollars worth of life-saving care they may not have received otherwise, or for which they would have had to pay high out-of-pocket costs. Hospitals enjoyed significant cost-savings thanks to the fact they did not have to rely so much on charity care, receiving compensation for services provided. “By training and hiring just a handful of staff members as financial navigators, hospitals have the potential to bring in millions of dollars of additional revenue,” Yezefski says.