Get uninsured to help themselves

Patients often have no idea they qualify

As a safety net hospital, Parkland Health & Hospital System in Dallas always has served the uninsured, and patient access employees have helped countless individuals to qualify for Medicaid, disability, grants, crime victims, or the hospital’s charity program. Recently, however, they have worked with many patients who have never sought any type of assistance before.

“In the last two to three years, we have seen numbers of the formerly employed grow,” reports Robert Reed, vice president of patient access/patient financial services administration. “We are seeing more people who are not your typical charity patients. They have lost their jobs and exhausted their unemployment, and are ill and need help.”

Patient access employees review about 9,000 applications every month, and they help 65% of the hospital’s patients obtain charity care and/or Medicaid coverage. An increasing number of these are employed individuals who can’t afford to purchase insurance. “We also screen them for any other benefits they may be eligible for,” Reed says.

Many uninsured patients are surprised at what programs they qualify for. For example, undocumented patients don’t realize they’re entitled to Medicaid coverage for emergency care.

“We dually screen them, both to reimburse us for that emergency, and also for our charity program to help them with medications, appointments, and follow-up care that may not be covered under Medicaid,” says Reed. Crime victims often are surprised to learn they’re eligible for a program that not only helps with medical bills, but also counseling and lost wages.

“Our patients are eligible for a multitude of programs, grants, disability, or any combination of those,” says Reed. “Our goal is to screen them for any or all programs. We try to get it all done upfront, so it does not slow them down.”

Once patients are covered by Medicaid, members of the patient access staff make them aware they can now make their follow-up appointments, obtain diagnostic tests, have prescriptions filled, and see a primary care physician. “If we can treat them before they become critically ill, they will stay out of the ED,” says Reed.

Parkland’s Transitional Care Unit strives to prevent readmissions in pneumonia, congestive heart failure, and myocardial infarction patients. “We are trying to target that population and get them to follow up on their treatment plan as they are supposed to,” says Reed. “We expedite getting them whatever coverage we can, so there is no lapse in their care.” Here are some obstacles that occur:

• Patients sometimes become defensive.

At times, patients hear the words “patient financial services” and assume the worst: that employees are there solely to collect large sums of money they simply don’t have.

To counter this perception, members of the patient access staff tell patients that they’re there to help them apply for any benefits that they might be entitled to. Next, they carefully explain the various types of assistance.

“Sometimes people have apprehension about applying for assistance for one reason or another,” says Bethanne Keating, associate director of patient financial services registration. “Patients have never been on charity before. They are unaware of all the different types of assistance programs.”

• Undocumented patients sometimes provide inaccurate Social Security numbers.

“They don’t realize they are potentially eligible for assistance. They give us a Social Security number because they think they need one, and we find it’s their child’s or someone else’s. That slows down the process,” says Keating.

Patients are more forthcoming when staff members first explain that no information will be shared with the Immigration and Naturalization Service. Then they ask the patient, “Where were you born?” instead of asking about their legal status.

• Patients don’t always follow up with requirements.

Because state and federal programs will deny patients coverage if they fail to submit required documentation, patient access employees “hold their hand through the process,” says Keating. Staff members ask patients to bring required documents directly to them, so employees can be certain they’re submitted, for example.

“We follow up with patients at their future clinic appointments. We contact employers for needed information, such as verification of income,” adds Keating. (See related stories on fraud prevention, below, and how to keep staff updated on changes in eligibility guidelines, below.)

Access took steps to combat fraud

If a patient insists he has no income, but he isn’t in arrears for a $1,200 apartment and a $600 car payment, what does that tell you?

Patients sometimes report little or no income to patient access employees at Parkland Health & Hospital System in Dallas, but they refuse to provide any paycheck stubs or bank statements.

“There are always those few bad apples that want to deceive you and think that if they say they have nothing, they don’t have to pay the bill,” says Bethanne Keating, associate director of patient financial services registration. “We work hard to educate our community that this is not ‘free care.’”

The patient access department made these changes, due to several recent incidents involving fraudulent claims made by patients:

• Staff members use a new interview process.

“We don’t accuse patients, and we work hard to teach our staff not to interrogate. But we do ask probing questions in a non-threatening manner,” says Keating.

Patient access employees tell patients, “You have a responsibility and a commitment to your healthcare as well. We are here to partner with you. To do that, we need truthful and accurate information. If you are honest and truthful with us, we are going to try and help you.”

• Patients are reported to law enforcement if fraud is suspected.

Robert Reed, vice president of patient access/patient financial services administration, says, “We have, in fact, prosecuted folks who have fraudulently gotten on our charity program, and are receiving restitution.” An initial investigation is performed thorough the Dallas County District Attorney’s office, he explains, and if it’s determined fraud has occurred, the matter is escalated to the Dallas County police department.

• Employees stress to patients that they are going to verify their address and income.

Occasionally, patients falsely claim to live in Dallas County to obtain charity care from the hospital. “We are not just taking their word for it,” says Keating. “Word of mouth has worked well. We have learned that our population is very tight-knit and communicate with each other extremely well.”

The department now uses third-party sources to perform credit checks and determine patients’ approximate household income, based on their spending habits.

• Patient access employees use software to verify information, and they screen patients for various programs.

“Previously, if the patient went to a different financial counselor, he or she might have gotten a different answer,” says Keating. “We took some of the subjective variables out of that.”

Keep staff current on ‘ever-changing’ rules

Obtaining documents to verify a patient lives in the state sounds simple enough, but it is sometimes challenging for patient access staff at Cox Medical Center Branson (MO).

“Our area has many people who are transplants from various parts of the nation who have not been living here for a very long length of time,” explains Rebecka Sandy, CHAA, CHAM, team lead for patient access. “They may qualify for Missouri State Health insurance pool or Missouri Medicaid. But without residency documentation, our hands are tied.”

Many times, registrars are able to obtain utility bills or credit card statements to use as proof of residency. In some cases, staff members have had to help the patient obtain a copy of their birth certificate in order to obtain a state-issued identification card.

Financial counselors now interview all self-pay patients to determine their ability to pay and whether they’re eligible for the state health insurance pool program and entitlement programs. However, programs and eligibility guidelines are “ever-changing,” says Sandy.

Patient access employees recently were able to enroll many patients in the federal health insurance pool for pre-existing conditions, for example, but no more applicants are being accepted. “We actually heard about closing of the federal insurance pool on the national news!” says Sandy. “This prompted us to inquire about the status with the administrator of the insurance pool within our state.”

Patient access employees learned that only patients who were eligible prior to March 1, 2013, are able to keep their coverage until the end of 2013. “We are now only able to enroll new patients in the state pool, which does not cover pre-existing conditions as the federal pool did,” she says.

Patient access managers work hard to keep staff updated on these and other program changes. “We frequently deal with patients that are from other states. It sometimes requires research to know the guidelines of their specific state,” Sandy adds.

Knowledge of the eligibility guidelines of various programs soon will become even more important for patient access, predicts Sandy.

“Access to affordable healthcare is ultimately the goal. But we need to be able to direct people to what would work best for them,” she says. “Being able to help the patient with these decisions reduces anxiety and raises patient satisfaction.”