Note fine line between assisting, soliciting

Overly zealous efforts draw charges of fraud

The woman at the registration desk needs medical care and has no insurance, but doesn’t have the pay stubs necessary to complete a Medicaid application. The staff member, feeling sympathy for her plight, says, "If you can’t find your pay stubs, just don’t mention your employment right now."

The patient thus qualifies for Medicaid, gets treatment, and your hospital gets its payment. But you might also find yourself in some legal hot water.

The financial squeeze being felt by hospitals that want Medicaid money and governmental agencies that are more hesitant about paying it can mean trouble for health systems. For instance, hospitals in Southern California have taken a beating in the press and been subjected to accusations of fraud and abuse from county authorities who believe the providers have crossed the fine line between assisting patients and soliciting them to sign up for government help.

"The problem that most often occurs, from my perspective, is [that] the hospital representative is sympathetic to the patient’s plight and aware he will not receive follow-up care unless he can demonstrate a method of payment," says Karma Hartman, project director for the Hospital Council of San Diego and Imperial Counties in California. "The hospital representative will pursue an application and somehow step over the line."

In San Diego, and in some other areas where there is no public hospital charged with providing indigent care, the situation becomes even more complicated, she says. Private health care facilities, through a partnership with the county government, provide the entire indigent care safety net. In counties with a public hospital, the county is at financial risk if it provides a large amount of unreimbursed care. But the county is not so worried about reimbursement when private health care providers bear that risk, Hartman contends.

While private hospitals are accused of having a conflict of interest by aggressively seeking payment for the care provided, the county can be construed as having a reverse incentive because the fewer people signed up, the less it costs the various government funding sources, she points out.

The plot thickens when you add in the complex regulations associated with MediCal, California’s Medicaid program, and the large number of legal and illegal aliens who are entitled to receive varying degrees of help from MediCal.

"The [county] department of social services has to send workers to class for six weeks so they’ll know how to make eligibility decisions," Hartman says. "For hospital employees, finding out what help patients are eligible for and helping them through the process is just one portion of their jobs. They often will make mistakes or give out incomplete information, and with a patient population that is unsophisticated or has language problems, it’s even more difficult."

The situation can become more problematic when there is an environment in which hospital employees or patients perceive that there is nowhere else to turn for information — that the government employee who is supposed to help is unavailable — or the hospital employee is not comfortable working with that government employee, she adds.

What can access managers do?

Access managers can help ensure the accuracy and integrity of their own financial assistance procedures, in several ways, including:

• providing inservices on public assistance programs for employees;

• developing a good relationship with the government representatives who oversee the programs;

• holding roundtable discussions with other access managers to see how they’re handing these issues;

• creating forms that document and standardize the way hospital employees interact with the public.

"Keep in close communication and develop a collaborative relationship with the local government body responsible for this eligibility [determination]," Hartman advises. "A lot of things blown up to epic proportions might have been prevented if there had been a better communication route open."

The Hospital Council’s report, Public Program Referral & Fraud Prevention for Hospitals includes tests that help measure an employee’s grasp of program regulations. (See sample tests on pp. 20-21.)

It’s also helpful to compare policies with other hospitals — even competitors, she notes.

Her council’s sister organization to the north, the Los Angeles-based Healthcare Association of Southern California, sponsors roundtables in which patient access managers from different hospitals talk about how their financial assistance programs are run.

"It’s a good preventive measure to talk with other hospitals to be certain things are done uniformly in any given region, so one hospital can’t be picked off," Hartman says. "If they’re all doing it, even if it’s incorrect, it’s unlikely to be determined to be fraud."

Look for any ways to standardize procedures and forms among hospitals, even if it means talking to your competitors about it, she advises.

Asking local government agencies to conduct inservices on Medicaid or MediCal is a good idea, she suggests. It allows hospital employees to ask questions, in a nonconfrontational setting, of those making the decisions, rather than questioning the government representative’s judgment later, in an on-the-job situation —never a good position to be in, Hartman adds.

[Editor’s note: Hospital Access Management is interested in your experiences in assisting patients to make application for government assistance. Please share any problematic incidents or innovative solutions by contacting Lila Moore at (404) 636-9264 or Glen Harris at (404) 262-5461. E-mail: We’ll include them in a future issue.]