Think like a payer when patients are uninsured

Decide in advance what and who to cover

In order to provide consistent post-acute care for uninsured or under insured patients, hospitals need to think like payers and develop a payment assistance policy so that at admission or registration, a financial counselor can do a quick assessment and determine who qualifies and who doesn't, according to Matt Boettcher, LSW, MSW, vice president for continuum of care for Scott and White Healthcare, with headquarters in Temple, TX, and consultant for the Center for Case Management, a patient care management consulting firm based in Wellesley, MA.

"When hospitals are in the position of providing care for the uninsured, they are not just being the provider of care, they are becoming the payer of care and they need to act like a payer," he says. When case managers call payers to get an admission or procedure approved, they get a decision on the spot. Hospitals need to have a plan to make the same kind of real-time decisions on care for uninsured or under insured patients, he says.

With 20% of Americans without health insurance, planning for care for uninsured patients is more than a once-in-a-while occurrence. "Providing care for unfunded patients is the norm these days. Hospitals need to develop a plan and avoid having to reinvent the wheel every time they get an uninsured patient," he says.

It's not a good idea to just have a committee that meets once a week. Instead, Boettcher recommends setting up criteria so the staff can make a decision in real time. "It doesn't pay for a patient to stay in the hospital until the committee meets on Friday, if the patient is medically ready to leave on Tuesday," he says.

Boettcher suggests that the policy be developed by a team that includes representatives from case management, admissions, registration, finance, and the physician staff. The policy should state for which patients you will provide charity care, and when you will not, and should be based on financial criteria.

For instance, the hospital may decide to pay for post-discharge services if a patients income is at 250% of the federal poverty level, and pay half if the patient's income is 350% of the poverty level. Whatever policy your hospital develops, it must be applied to every patient in the same way, he says.

"Hospitals must follow the policy consistently and not have the appearance of favoritism," he says. For instance, hospitals shouldn't put themselves in the position of paying for post-acute care for a patient of a doctor who admits a lot of patients, and refusing to do so for other patients in the same financial situation.

At Scott and White, when a patient doesn't need a walker, a prescription, or transportation to the doctor, the case manager can determine if the patient qualifies, and set it up on the same day. "This is an effective way to make a decision and it's the way a health plan functions," he says.

A well-developed plan to provide post-discharge assistance for the uninsured helps everyone. The case managers can spend their time with all of their patients. The hospital doesn't make a decision every time there's an uninsured patient who needs post-acute care, and the patients can get the services they need.

"I want my case management and social work staff to be able to provide good care to all patients. Calling pharmacies for prescription assistance, or trying to get a skilled nursing facility to take a charity case can take an entire day and the case manager's other patients get nothing," he says.