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In 2010, Sutter Health Sacramento (CA) Sierra Region, which consists of eight acute care hospitals, saw a 30% increase in its uninsured population.
"We had not anticipated the national financial downturn or the subsequent influx in our uninsured population," says Michael Taylor, regional director of patient services and patient access/financial services. "Thankfully, our structure was in place to handle the volume and assist these patients."
Two years ago, patient access leaders redesigned the financial counseling model to place more emphasis on uninsured patients, due to a minor increase that had been identified, he explains. "We were also aware that one of the deliverables of healthcare reform was to make new programs available for uninsured patients," adds Taylor. "An increased need for assistance was expected."
There was also a Medicare affordability initiative throughout the organization, focused on reducing the operational cost of providing healthcare services to the communities served, adds Taylor.
One of the opportunities identified to reduce costs and improve patient assistance was vendor costs of $1.4 million annually, which was being spent to assist patients with eligibility for government programs including Medi-Cal, California's Medicaid program, he says. "We also felt that our present model for assisting the uninsured and underinsured was very confusing for our patients," says Taylor.
Previously, patients would meet with a financial counselor to validate their uninsured status, be introduced to a representative from the eligibility assistance vendor, and receive post-service collection calls and separate customer service assistance if the patient had questions regarding their account. "The process was redundant and provided suboptimal support for this patient population," says Taylor.
A patient financial advocacy workgroup was created, with hospital employees placed at each of the eight facilities, as part of a comprehensive redesign of the patient access and patient accounting departments.
The advocates help uninsured patients enroll in government programs, identify other payer sources such as COBRA, give service cost estimates, and offer charity assistance. "We were able to accomplish this without increased staffing, by centralizing the insurance verification, notification, and authorization processes. This was traditionally part of the financial counselor workload," says Taylor. "We also assigned private-pay collection resources to the front end."
The objective was to evaluate all functions performed in all areas to avoid redundancy, improve quality, and reduce cost, says Taylor.
Traditional patient access functions including insurance verification, authorization, notification, pre-registration and, in one service line, scheduling, were centralized in the business office along with billing and account follow-up. "Financial counseling and private pay collection were combined," says Taylor.
The workgroup employees were trained in screening for all potential payers, charity, and bad debt management, says Taylor. "The employees chosen all had some exposure to facets of private pay patient assistance, but a more comprehensive knowledge was required," he explain. These steps were taken:
Training was provided by the hospital's government program conversion specialist, who had extensive experience in government screening and eligibility. The hospital's bad debt and charity coordinator trained staff on private pay collection and charity determination processes.
"We still retained an outside vendor to assist with disengaged patients, or patients that required home visits to assist with application processes," says Taylor.
The vendor cost for eligibility assistance decreased from $1.4 million before the transition to $100,000 in 2010.
The workgroup was made responsible for all uninsured and underinsured patients, which are defined as insured patients with a patient liability of $5,000 or greater after insurance payment.
"Assistance provided includes government program eligibility assistance, or other payer assistance such as COBRA or third-party liability, service cost estimates, charity eligibility, and payment plan assistance," says Taylor.
One to three advocates are located at each facility, based on patient volume.
Three advocates work in the central business office to assist scheduled patients during the pre-registration process, adds Taylor.
The workgroup is measured on private pay accounts receivable days, accounts converted to government programs or alternative payer sources, accuracy of estimates, private pay cash collection, charity determination, and reduction of fees paid for vendor assistance.
Private pay cash collection, which averaged $1.4 million in 2009, increased to an average of $1.9 million a month in 2011, and the number of inpatient accounts converted to government or insurance payer increased from 2,052 in 2009 to 2,533 in 2010, reports Taylor.
The advocates are responsible for managing the account through collection, government or other payer conversion, payment, or adjudication.
"The patient has one employee to communicate with, from point of service through the aging of their account," Taylor says.
For more information on improving financial counseling processes, contact:
Michael Taylor, Regional Director, Patient Services and Patient Access/Financial Services, Sutter Health Sacramento (CA) Sierra Region. Phone: (916) 978-8901. E-mail: firstname.lastname@example.org.