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Certain patients who say they do not have any insurance actually are covered in some way. It is the job of patient access staff to find it — and avoid uncompensated care for the hospital.
“Hidden revenue is always good revenue,” says Cheryl Barrett, patient access director at Parkland Health & Hospital System in Dallas.
Regardless of whether patients are unaware of their coverage, or withhold the information on purpose, some detective work is needed. This is where the hospital’s financial assistance policy comes in handy.
“It should require patients to cooperate with applying for any potential insurance coverage,” says Valerie A. Rinkle, MPA, CHRI, president of Valorize Consulting, a Medford, OR-based firm specializing in revenue cycle management.
Efforts on the part of patient access to find coverage can decrease bad debt. “Usually, the total is reduced by investing in more comprehensive and better upfront processes,” Rinkle notes. The following are certain cases when people present as self-pay when they actually do have some type of insurance coverage:
• Some people do not admit they have insurance, only because they do not want to pay their deductible. The hospital’s discounted self-pay rate could end up lower than a high-dollar deductible. “As a result, patients consider themselves self-pay instead of sharing the insurance information,” Barrett explains.
Many underinsured patients still cannot afford their out-of-pocket costs but assume the fact they do have insurance disqualifies them from receiving financial assistance. That is not always the case, since policies typically apply to anyone with out-of-pocket expenses they cannot afford.
“Even if their deductible is $7,000, the hospital may determine the patient does not owe this amount due to financial need,” Rinkle says.
• Patients may have tried to obtain coverage at some point, but lost track of their enrollment status. “We have found this to be the case with patients who are transient,” Barrett reports. Some patients completed forms electronically using an email address they can no longer access. Other patients lost paperwork during a recent move.
• Patients with injuries do not know their medical expenses are covered by third party liability insurance. Some do not realize their employer provides workers’ compensation insurance. “Patient access needs to perform a thorough intake of patients to determine any potential coverage for injuries, even if the visit is not on the same day as the injury,” Rinkle stresses.
• Newly hired patients do not realize their coverage is effective already. One Parkland patient said he had not been on the job long enough to receive health insurance. Patient access staff found out that coverage started on the first day of employment. “In most cases, patients are not educated on their coverage,” Barrett laments.
• Patients who recently left a job assume they have no coverage. Many believe coverage ends on the date of resignation, termination, or retirement. “However, the end date of your health insurance may differ from the employer’s termination date,” Barrett says.
The same applies to many plans purchased on the Health Exchange Marketplace. “The end date normally has a grace period in which the insured is still covered,” Barrett adds.
• Patients with chronic conditions, including cancer, may qualify as disabled. “This immediately qualifies them for coverage under their state Medicaid program, and may also provide a monthly income,” Rinkle reports.
After two years, the patient would qualify for Medicare coverage. People do not always apply for disability coverage. “There may be stigma or a concern that it is too hard to apply,” Rinkle says. Looking at the diagnoses of patients seen repeatedly can identify people who are likely to qualify for disability.
• Divorced patients do not realize they are still covered under a spouse’s insurance plan. One man told registrars he had no insurance, was not employed, and was a stay-at-home parent. When staff asked how he was paying his bills, he said his family was helping out after a divorce. Staff asked the patient if he had been covered under his spouse’s insurance. The answer was yes, so staff followed up with the spouse. “He was actually still covered under her insurance plan, but thought that she’d removed him since the divorce was finalized,” Barrett says.
To ensure any coverage a person has is identified, information is power. “We depend on intuitive technology and employee interviewing skills to find healthcare coverage,” Barrett notes.
The tools can shed light on the person’s address history, coverage history, and credit history. Barrett says registrars need to ask detailed questions. “The same screening questions need to be asked each and every time the patient presents for service,” she stresses.
Sometimes, a surprising piece of information comes from the clinical side — a case manager, nurse, or social worker. “There is a higher trust factor between the patient and the clinical partner,” Barrett observes.
Patients may share something with a clinician they do not tell the financial team. One 72-year-old patient presented with an extended illness. He said he never applied for Medicare, was self-employed, and did not have any emergency contacts.
However, a social worker revealed that when the man was about to leave the hospital, he mentioned his sister would assist with post-discharge care. “We contacted the sister to determine the coverage history. She didn’t understand why he didn’t have coverage because he was a veteran,” Barrett recalls.
Registrars investigated further, and learned that the man was covered, but had never used the service. “The patient said that he didn’t recall that he was eligible for VA services,” Barrett says.