Navigating Reimbursement Solutions
by: Lisa Mathews
About the Author, Lisa Mathews
Ms. Mathews is a native of Jacksonville, Florida and has over 20 years experience in the Health Insurance Industry. She is currently the Director of Marketing for Adreima.
Simply put, navigation first begins by identifying your end point and then charting a course to get to your known destination.
When it comes to reimbursement solutions for self-pay uninsured patients, the destination point is easy – reimbursement for incurred hospital costs. The hard point comes in charting a course to get there. There isn’t always a direct line from point A to point B and often times it is worth while to stop and explore alternative paths along the way.
Today’s economic conditions are impacting more and more Americans everyday and reimbursement for healthcare is one of the Country’s biggest concerns. The latest Census data show 50.7 million Americans were uninsured in 2009. This number is staggering when you think about the factthe uninsured will spend $30 billion out-of-pocket for health care in 2008 while receiving $56 billion in uncompensated care, three quarters of which will be from government sources. ¹ Furthermore, most uncompensated care dollars are incurred by hospitals, where services are most costly. Consistently in prior years, hospitals accounted for over 60% of uncompensated care dollars.
Hospital revenue cycles are negatively impacted year over year by lost, unreimbursed patient accounts. In order to lesson the impact, it is imperative that hospitals maximize the opportunity to secure some form of reimbursement for all patients who present without insurance.
With this said, determining eligibility and managing the reimbursement process has become a highly specialized and complex discipline. There are many avenues that can be pursued when seeking reimbursement solutions. Medicaid and Social Security Disability Insurance Income (SSDI) are at the top when it comes to solutions, however, there are many more such as:
County Assistance Programs; Rx assistance;
Exhausted benefits (appealing Medicaid days);
Medicare deductible (QMB);
Charity Care Funds
Often times hospital systems focus on only one or two potential solutions. This is primarily due to a lack of core processes, resources, and expertise in other solutions.
Since lowering administrative costs is important to most hospitals, patient financial assistance is a key area to evaluate efficiencies in. All components of your patient financial assistance program; including people, process, and technology; should be explored in the assessment phase. An opportunity may exist in one or more of these areas that could ultimately improve the eligibility process resulting in better financial outcomes for both the hospital system and the patient. Improvements in outcomes can be realized with small tweaks to your existing processes or perhaps by adding new capabilities and additional resources.
The patient financial assistance screening process is a good place to start when beginning your overall assessment. This phase can be viewed as the beginning of the “advocacy approach” for reimbursement. By acting as an advocate for the patient you can successfully aide in navigating a patient through the myriad of reimbursement solutions. Investing time up front in the screening/interview process can yield big rewards in the end. Patients may be eligible for multiple programs therefore multiple applications can essentially be submitted at once. Some important points to capture during that first phase include:
Is the patient a minor under 18 years of age?
Is the patient pregnant?
Is the patient between 18 and 20 and still living at home with parents?
Is the patient over 65?
Is the patient disabled?
Is the patient permanently blind in both eyes?
Is the patient working? or how much have they worked in the last 10 years?
General income & asset information.
The answers to many of these questions and others can steer you in the direction of which reimbursement solution(s) the patient may be qualified to apply for. When evaluating your screening process be sure to assess all components again. For example, People - Do you have enough resources to thoroughly screen? Process – How efficient is the screening/interview process? Technology - Are there any capabilities that could enable this process?
Although the screening process is a critical element, it alone does not guarantee positive outcomes. Monitoring and evaluating is also essential when it comes to ensuring the overall effectiveness of your patient financial assistance program. Therefore, reporting should be an area that is including in your overall assessment. Regular evaluations of outcomes is not only important to revenue cycle management it can aid you in identifying areas of opportunity. As an example, the percent of uninsured accounts converted to payment is a critical financial performance indicator, however, the data is even more useful if you can distinguish by type of reimbursement. This could reveal whether or not multiple solutions for reimbursement are being pursued. If your current reporting infrastructure is not supporting these areas of measurement this could be an opportunity for improvement.
In closing, whether you have an in-house infrastructure or are outsourcing services to a vendor, an end-to-end assessment of your patient financial assistance program is important. All steps of the eligibility process including screening, application, tracking, approval, appeals, and reporting should be part of the assessment. Remembering to evaluate the three main components of people, process, and technology while assessing each step will ensure a thorough assessment.
With the population of uninsured self pay patients growing everyday, an assessment of your current state is a proactive approach for planning for your future. Efficiently securing reimbursement solutions for uninsured self pay patients will result in positive impacts to your hospital system revenue cycle, as well as enhance overall patient satisfaction.
