Coverage for unfunded is access director’s specialty

Initiatives brought millions in reimbursement

"If the front end would just get it right when the patient first comes in . . ." goes the refrain from billers, or the CFO, or some other party focused on putting the blame for unreimbursed care at the feet of the access department. But when a substantial number of patients walk in without insurance coverage at the time of care or are emergency patients who don’t have their insurance information with them, it’s not quite that simple, says Patti Daniel, MS, CCM, LPC, LMSW/AP. And when many of those patients also are undocumented immigrants, she adds, the challenge is that much greater.

"It’s always best to obtain the information up front if it is available; but if it isn’t, you have to create processes to identify or develop funding as quickly as possible after the fact," says Daniel. Her focus has been on doing just that during a recent five-year stint as director of admissions and registration at a publicly funded hospital with more than 900 beds. She currently works as a health care consultant based in the Dallas area. "We were the designated indigent health care provider for the county," she notes. "People came there because [their perception was] the hospital would provide care at no charge."

During her tenure as director, Daniel adds, she created initiatives that recouped millions of dollars in what would otherwise have been uncompensated care. The centerpiece of that effort, she says, was a strong financial counseling unit that comprised several programs aimed at obtaining financial coverage before the patient was discharged and after patient care had been provided.

The 37-week process

Patients who are undocumented U.S. residents — and so not eligible for traditional Medicaid — are eligible for coverage of costs associated with the delivery of a child, which is considered an emergency, Daniel explains. Although the hospital could receive between $1,800 and $2,200 from Medicaid for the delivery based on the institution’s standard reimbursement rate, that reimbursement happened only if the patient was certified for the coverage, Daniel says. While patients would sometimes get certified in order to receive a year of Medicaid coverage for their babies, she notes, they had no incentive to get certified so that their own hospital bill for delivery charges would be covered.

In fact, Daniel points out, undocumented patients often avoided making the Medicaid application that could qualify them for payment of their hospital bills for fear that the hospital would report their illegal status. Meanwhile, she adds, these patients "could care less if we turned the bill over to a collection agency, because they don’t care about personal credit. Most are not buying houses or getting a car financed. They’re trying to avoid being sent back to Mexico."

In order to recover these hospital delivery costs, Daniel says, "we created what I call the 37-week process. It’s pretty simple, but you have to stay right on top of a person’s pregnancy and Medicaid application status."

Undocumented patients were identified at their initial prenatal visit and during the 35th week of pregnancy, she notes, and given a Medicaid application to complete. They were told that when they reached the 37th week, they should bring the application back, with the required documents, and would be assisted in applying for emergency Medicaid coverage. "We explained that the required documentation included such things as a birth certificate, the number of people in the family, proof of residency, and household income," Daniel adds.

The process was facilitated, she says, by a database she created that was shared by the financial counselors at the hospital and those at eight community-based prenatal clinics, who worked in tandem to get the patients’ bills covered by Medicaid.

In the 37th week, Daniel explains, hospital financial counselors made an appointment for the patient with a hospital-based Medicaid eligibility worker to complete an application, which was put on pending status until delivery. The financial counselors, meanwhile, created a pending pre-admission account, which was tracked through the expected delivery date.

Timing was crucial, she adds, because Medicaid workers are allowed to hold an application only about a month before a decision must be made. "That allowed about four weeks after the application was submitted for the person to deliver, which typically happens in the 40th week, Daniel says. During that hospital stay, financial counselors immediately assisted the patient in completing the two or three remaining forms required for coverage and made sure she added the new baby to the application.

Patients in this group move frequently, she notes, and often live with relatives. "Once they leave the hospital, you’ve missed the golden opportunity [to obtain coverage]. This process resulted in the highest certification rates ever for that hospital — 92% for the mothers and 96% for the babies — and some of the highest in the state of Texas," Daniel adds.

After creating the follow-up unit, she says, her staff began identifying patients who had followed through with applying for Medicaid but never let the hospital know of their certification. To make the identification process cost-effective, she says, the unit checked Medicaid status electronically. "We sent large files containing inpatient names to the state Medicaid office through a clearinghouse and received matching patient names that were certified for Medicaid. There could be as many as 450 women in the state of Texas during a specific month with the same name; so research — finding the right birth date, double-checking addresses — had to be done once the list of matches came back."

Spend-down’ candidates sought

Another function of the self-pay follow-unit was tracking people who qualified for the "spend-down" program, Daniel explains, which applied to those who had enough income that they were not eligible for traditional Medicaid.

If the people — whether couples or single adults — had children, and if they had unpaid medical bills, she says, they sometimes qualified for Medicaid even if the income was much greater than allowed by traditional programs. "There were still income guidelines, but they were not as stringent."

To determine the spend-down amount, Daniel says, financial counselors referred patients to the Texas Department of Health Services (TDHS), whose Medicaid eligibility workers took the person’s financial statement and did an accounting of household bills. "[The patient] might be required to pay, for example, $600 of his or her medical bills before TDHS would begin reimbursement to the hospital," she explains. "[TDHS] figures out what is left after such expenses as gas, water, rent, unpaid medical bills, and transportation to work. These allowable expenses represent the spend-down amount. Medicaid reimburses the hospital on Medicaid rates less the spend-down amount."

While the typical procedure is that people applying send in their bills and Medicaid reimburses them, Daniel says, she found that patients could not be counted on to complete that process. "It’s a complicated program to administer, so we worked out a system," she adds. "We monitored patients with continued medical bills, tracked the bills for them, and got a waiver signed so we could send the information in to Medicaid for them."

The reimbursement generated in this way "represented millions of dollars a year to the hospital," Daniel notes.

Inpatient non-OB initiative

Another self-pay initiative involved training five or six financial counselors to screen for potential disability determination benefits, she says. "What we were looking for is the person who was not eligible for anything else — no Medicaid, no Medicare, no minor children in the home, minimal income, and not pregnant." A patient who might qualify for this assistance "could be a burn victim, someone in a car wreck, or a person with severe trauma, such as a head injury, who will be disabled for at least 12 months," Daniel explains.

The counselors helped the patients complete an application for disability through Social Security or the Supplemental Security Income (SSI) program, she adds. SSI is designed to help aged or disabled individuals who don’t qualify for traditional Social Security or whose Medicare benefit is below a certain limit, Daniel notes. "They may be eligible for both [Social Security and SSI], so we applied for both. It takes a long time, an hour to an hour and a half, to complete the screening interview and the application."

Without the proactive step of interviewing the person while he or she is still in the hospital, Daniel points out, the opportunity is often lost. "They leave, and a lot of times they don’t go home. They are so sick, they might go to a rehabilitation center, or they could move, and then you’ve lost a way to reach them."

While the reason for the effort is to get patients’ medical bills paid, she notes, those who qualify also benefit in another way. "If they get on the program, they get a disability check to help with living expenses."

(Editor’s note: Patti Daniel can be reached at Look for more on how Daniel designed a successful access department in the March issue of Hospital Access Management.)