No stone unturned in self-pay initiative

90% of Medicaid-eligible gain coverage

Responding to a rising number of self-pay patients — particularly those coming through the emergency department (ED) — Children’s Healthcare of Atlanta (CHOA) pulled out all the stops to expand and improve its financial counseling program.

As a result, CHOA — which comprises Scottish Rite and Egleston children’s hospitals — now gets coverage for 90% of all patients who are eligible for Medicaid, says Benna Gilkey, manager for financial counselors for CHOA and patient access manager for the day surgery and main admission areas at Egleston. The 10% of patients who aren’t approved are those who don’t follow through by bringing in the necessary information, she notes. "If we take the application, the likelihood of being approved is close to 100%."

"What’s really behind our success rate is that we changed the whole mindset, and became more proactive as we added team members," Gilkey says. "We became true gatekeepers, and to do that you have to be equipped to tell the customers what their next step is."

CHOA recognized the increasing financial counseling workload and realized much of the self-pay volume was coming through the ED a little more than two years ago. Therefore, they added ED financial counselors at each of the hospitals, and a part-time person who works 1 p.m. to 5 p.m. Saturday and Sunday at Scottish Rite, she notes.

They joined the two existing inpatient financial counselors, one at each facility, and one financial counselor who works with outpatients at the Scottish Rite clinic, Gilkey adds. "On the main campuses, the inpatient counselor works 7 a.m. to 3:30 p.m., and the ED counselor works 1 p.m. to 8:30 p.m., so they complement each other, time-wise."

The financial counselors’ job, she says, "is to ensure that all self-pay inpatient, observation, and ED registrations — as well as any self-pay accounts more than $1,500 — are evaluated for third-party coverage." That includes diagnostic, laboratory, and rehab services, she says. "We also [work with] anyone else who expresses interest in obtaining coverage."

On-site DFCS representative tool

A big part of CHOA’s success in gaining coverage for its self-pay patients is because there is a representative of the state Department of Family and Children Services (DFCS) on-site at each hospital campus, Gilkey notes. "Both on-site caseworkers are there Monday through Friday, 8 a.m. to 6 p.m.," she reports. "Our financial counselors can clear the applications and turn them right over to [the caseworkers]. Our turnaround time is quick. We get the applications prior to discharge and they are completed and handed over to DFCS to load [onto the state web site]. We have that capability right in our office."

In many cases, financial counselors do an assessment with a family member, get the application processed by DFCS, and are waiting for approval all while a patient is in surgery, Gilkey points out. "As long as [families] provide the information that is required, we know they will be approved, because DFCS is there to complement the financial counselors," she says. "It’s a great relationship. Our financial counselors are very familiar with state requirements and policies for approval, and they ensure that every piece, every document required, is available."

Financial counselors work very closely with patients’ families in making the application for assistance, Gilkey notes. "It’s hands-on. We have a checklist, and we make sure everything on that checklist has been completed. We do our applications here — it’s basically a hand-held process. We make sure we’re satisfied with the application."

Because of that close attention, financial counselors are able to determine during the initial assessment whether a family is going to be noncompliant (meaning they don’t bring in the necessary documents or otherwise appear unwilling to pursue coverage), or if the patient’s condition is a disability that may be covered under the Supplemental Security Income program, she explains.

If so, the case is referred to an outside vendor agency, that, as part of its contract with CHOA, will continue to try to get coverage, doing home visits if necessary, Gilkey says. If the vendor is unsuccessful, she adds, the account is turned back over to the hospital, which may send it to a collection agency.

The comfort level that is established between CHOA’s counselors and the patients they serve is such that patients often come back to them about concerns that are not related to obtaining financial coverage, she points out. "We have had families show up with letters they had received from other caregivers and ask my team to explain what’s needed and what they’re supposed to do," Gilkey says. "In most of those situations, it’s just a matter of providing their insurance or Medicaid information to those providers, which results in a win-win’ for everyone."

Another plus for the CHOA program is that three of its financial counselors — one at Egleston and two at Scottish Rite — are bilingual, she says. "In the beginning, [speaking Spanish] was a plus," she recalls. "Now it’s really a plus, but it’s not a [requirement], because we do have translators. It’s a good asset that makes the process a whole lot faster."

Taking the extra step is part of her team’s normal operating procedure, she says. "If someone is signing up for assistance, we ensure that every dependent in the household is approved for aid. We look at it from the perspective of the whole family."

When financial counselors receive an account that appears to be self-pay, they check hospital and physician databases to determine if the patient has visited any of CHOA’s facilities before, and if there was past insurance coverage, she says. "If so, we run that through our insurance verification system and see if the insurance is still valid."

If counselors find a Medicaid account that has been closed, they call the parent to find out what happened and, if they can’t reach the parent, they take the account number to the DFCS workers and ask them to research it. "A lot of times a relative [other than the parent] brings in the child, and our system has a lot of entry points," Gilkey notes. "Just because you’re registered as a self-pay, that doesn’t mean you are a self-pay. We leave no stone unturned."

[Editor’s note: Benna Gilkey can be reached at (404) 785-6334 or by e-mail at benna.gilkey@choa.org.]