Millions of people are uninsured, unemployed, and unable to pay their hospital bills. Patient access is stepping in to offer all kinds of help.

“We are seeing a larger increase in patients wanting financial assistance,” reports Linaka Kain, DE, regional manager of patient financial coordinators and the marketplace exchange for UnityPoint Health.

UnityPoint’s financial assistance programs are primarily for uninsured patients facing catastrophic medical bills. They are not necessarily for those who present with insurance but still face paying high out-of-pocket costs. “Also, even if someone does qualify for financial assistance, it only helps them at the hospital they incur their medical bills at, as an option of last resort,” Kain explains. If the person goes to a different hospital, he or she would need to re-apply to see if they meet that hospital’s criteria.

Financial coordinators first check to see if those with private commercial insurance can qualify for Medicaid as secondary insurance coverage. “That’s going to help them with every medical bill they incur, at any hospital,” Kain notes.

If the patient is well above the federal poverty level and has commercial insurance, “there’s not much you can do for those people,” Kain says. Payment plans or low-interest loans are offered. For some, the biggest worry is they will not qualify for a loan. “When they find out no credit check is run, they breathe a sigh of relief because they know their credit is not very good,” Kain observes.

Sometimes, the patient can afford the payments at first, but things change for the worse. If someone cannot make the payments later, “then we have to go to financial assistance,” Kain reports.

Financial coordinators routinely screen inpatients to see if they might qualify for Medicaid. Many skeptical people say, “There’s no way I’ll qualify. I make too much money.”

“Those are the people who actually end up qualifying,” Kain says. “They just don’t know how to figure their income out the way that DHS or the marketplace is looking at it.”

There may be an instance when the patient’s diagnosis makes him or her eligible for disability because the patient cannot work through treatment. “We can get them signed up for Medicaid. There are assistance programs that can get them free medication for two or three months, which really helps,” Kain says.

Financial coordinators ask six screening questions to identify if someone is eligible for Medicaid. If the person is eligible, he or she completes a Medicaid application immediately. “The name of the game is doing everything you can all at one time,” Kain stresses.

Staff apply for the hospital’s in-house program for medication assistance. They also apply for any community benefits that might be available, and examine whether financial assistance is an option. “We apply for anything we determine the patient may be eligible for. It’s a one-stop shop we are trying to do so the patient doesn’t have to come back and be inconvenienced,” Kain says.

Many do not expect to meet criteria for any help. “They are surprised because they have not been educated in what’s available to them,” Kain says.

Perhaps someone applied for Medicaid previously and was rejected because his or her income was too high. When things change (e.g., job loss or hours reduction), those people assume they cannot apply again until the following year. “Not working overtime any more, or losing their job, could put them within different criteria,” Kain explains.

That is because while other programs consider yearly income, Medicaid is concerned with monthly income. Financial coordinators ask these questions:

  • What is your total household income?
  • Have you applied for insurance in the last three months?
  • When is the last time you had insurance?
  • Are you currently employed?
  • What is your rate of pay?
  • Have you lost a job recently, have your hours been reduced, or have you been laid off?

These days, many people answer “yes” to this last question. Most are quite surprised to learn they still have coverage through their former employer. “They think that if they quit or got fired that their coverage ends that day. That’s not the case,” Kain underlines.

The coverage still may be good through the end of the month, or may be good for an additional month. Some people have a 60-day window after leaving or losing a job to qualify for a special enrollment period through the Health Insurance Marketplace. “The majority of people just don’t know,” Kain says. “It’s all about asking the right questions.”

At Novant Health in Winston-Salem, NC, patient access made two changes:

Staff are placing temporary holds on accounts if patients express concerns about their ability to pay while out of work. This buys patients time to figure out a solution, as opposed to allowing accounts to go to collection. “Those holds will be revisited periodically to determine if they should be released or extended,” says Elkin Pinamonti, MHA, CHAM, assistant director of patient access.

A new process uncovers cases for which insurance has denied a claim. Staff proactively contact the patient to offer assistance. “We refer any visits within the retroactive eligibility period to be screened for Medicaid,” Pinamonti says.

Certain patients do not qualify for Medicaid. Others qualify, but the visit date falls outside the retroactive eligibility window. Those problematic accounts are routed to a financial counselor who contacts the patient. Together, they create a plan. “Patients are surprised that even if they do not qualify for a full charity adjustment, they can sometimes qualify for a significant discount,” Pinamonti reports.

These pleasant surprises are becoming more common. Almost half of uninsured adults may have been eligible for subsidized insurance (either through the Health Insurance Marketplace or their state’s expanded Medicaid program).1 “Either they are eligible for Medicaid, the kids are eligible for CHIP [Children’s Health Insurance Program], or they are eligible for the marketplace with premium subsidies or cost-sharing reductions,” says Jack A. Meyer, PhD, an independent healthcare consultant.

For the patient access role, it means a shift away from upfront collections. Instead, staff are focused on assessing people for eligibility for various programs. “We are not just talking about poor people here. We are talking about a lot of middle-income people, too,” Meyer says.

For eligible patients, Medicaid pays virtually all of the hospital bill. For the hospital, it means much-needed revenue. “They’ll get Medicaid payments, which are lower than commercial insurers, but it’s about 70 cents on the dollar. If I had a choice between getting 70 cents on the dollar and zero, that’s not a hard choice,” Meyer offers.

Many hospitals have fine-tuned processes to tell people their out-of-pocket costs. But this transparency about costs is not enough at this point. “You can be transparent, but if being transparent is telling the person it’s going to cost thousands of dollars, and they can’t afford it, what good is it?” Meyer asks.

For instance, many cannot afford to pay their deductible. “Some hospitals may work with health plans to waive or cover the deductible in some cases,” Meyer says.

The hospital might pay the deductible. Patients receive needed medical care, and the hospital receives some reimbursement from the health plan. “This prevents the hospital from billing the account for five years and getting stuck with bad debt,” Meyer adds.


  1. Gunja MZ, Collins SR. Who are the remaining uninsured, and why do they lack coverage? Findings from the Commonwealth Fund biennial health insurance Survey, 2018. Aug. 28, 2019.