University of Virginia Medical Center A case history on government program eligibility for self-pay patients Our unique vision has made us the leading provider of comprehensive patient eligibility services to America s hospitals. 800.255.0953 www.chamberlinedmonds.com
Background It is no secret: Every year, millions of dollars literally walk out the door of hospitals nationwide. The main cause for the revenue gap is uninsured, indigent patients. Charges for these patients often end up either as charity care or bad debt write-offs. Both of these unpaid "buckets" are bad news for any hospital s books unless the hospital can get the charges shifted into paid categories. One way to do that is to capture funds from government-subsidized reimbursement programs. These can include Medicaid, Medicare, Social Security disability, as well as state and community-funded programs. But qualifying a patient for government funds isn t always easy. For many indigent or disabled patients, the application process is fraught with frustrating denials and delays. Few patients understand the system well enough to fight a bureaucracy alone. And few hospitals have the resources to help patients cope with the tedious approval process. The University of Virginia (UVa) Medical Center in Charlottesville, Virginia was facing a similar dilemma. 2
UVA Med Center Snapshot University of Virginia Medical Center Charlottesville, VA: Problem: Solution: Results: (6/2002-12/2010) Projected ongoing benefits: Major teaching hospital 622 staffed beds 1,474 nurses 29,922 admissions and 35,600 emergency room visits in 2009 Named a Solucient "Top 100 Hospital" Money lost due to lack of resources for charity and uninsured cases for government-funded programs Chamberlin Edmonds retained to audit reimbursement procedures, recommend changes, and serve as patient s advocate in applying for government assistance Accepted more than 31,300 patients for benefit applications Over 24,700 cases approved Over $448 million in gross charges approved Recovered more than $143 million in cash to the hospital Annual cash impact of conversion of uninsured to a paying category Annual DSH increase Participation in programs offering favorable drug pricing for the indigent Improving patients financial situation 3
Outside expertise sought to increase revenue At UVa Medical Center, a county- and hospital-funded Medicaid Unit was responsible for processing new applicants. However, neither the Medicaid Unit s staff nor the hospital s staff had the resources to aggressively seek out patients eligible for government-funded programs. Recognizing the opportunity to recover more revenue, hospital officials decided several years ago to explore using outside expertise to identify qualified applicants and to work closely with them through the approval process. "We knew that many of the patients in our bad debt file might qualify for disability, but we also knew that an effective process would require unique skills and dedicated staffing," said Brent McGhee, the Medical Center s administrative manager of patient financial services. "So we sought an outside firm to do two things. First, assess our process and recommend improvements. Second, implement the improvements and run the process through a contractual relationship." Estimated new cash: $15,000 per case In the fall of 2001, UVa Medical Center issued a request for proposal (RFP) for a firm to address these two items. A few months later, the hospital selected Chamberlin Edmonds as the winning supplier for its new Health Care Government Eligibility Program. Chamberlin Edmonds completed the Medical Center s Eligibility Assessment in January 2002. The report cited the hospital s key strengths, including strong management commitment, a positive patient advocacy environment, good reporting systems, and many available assistance programs. The report also recommended organizational and process improvements that could lead to 507 converted cases per year at $15,000 per case a potential cash reimbursement of $7.6 million per year. Some groups in the hospital were initially skeptical. To build a consensus, McGhee gave the various departments an opportunity to voice their concerns. "I let everyone know that I would be reporting progress to the administration in monetary terms." As the Medical Center s contracted eligibility specialist, Chamberlin Edmonds began working directly with patients in July 2002 as their legally appointed representative with Social Security and state programs. 4
The Chamberlin Edmonds process Chamberlin Edmonds has five healthcare representatives (HCRs) at the hospital. Each representative gets 10 to 15 case referrals a day directly from the Patient Financial Services department. For each referral, HCRs prepare an assessment of opportunities for government assistance or other coverage. They meet patients, social workers, doctors and nurses to gather information, prepare claims and supporting documentation for submission, and aggressively follow up with agencies to obtain approval of benefits. Chamberlin Edmonds handles the application process and all appeals at no cost to the patient. Applications get accelerated The guidelines for approval are strict. In Virginia, 61.6% of initial applications are denied by the Social Security s Disability Determination Services. "We typically can cut about 90 days off Social Security s processing time, and get more initial applications approved, because we know what to supply," said Sarah Boyd, the Chamberlin Edmonds eligibility expert who performed the process assessment at UVa Medical Center. "We help the denied applicants go through the appeals process, and often we win because the judge can assess the patient s condition in person." The easy part of tapping government funds, McGhee noted, is converting the "slam dunk" cases, such as adding a baby to the mother s Medicaid or helping an over-65 patient qualify for Medicare. "What is often missing is the up-front investment in full-time resources to uncover previously unidentified funding. Then, it takes daily tracking of every self-pay, indigent patient month after month to ensure program success." Positive results McGhee estimates that, with Chamberlin Edmonds as its eligibility specialist, UVa Medical Center is capturing a significant amount of the money it was once leaving on the table. In fact, the cash impact has proved to be more than Chamberlin Edmonds initially projected. "If we look at disability conversions alone, the result is huge," he adds. "Since the program started, more than $143 million of charges have been moved from self-paid, uninsured status to covered by Medicaid. Much of these charges would have likely ended up as bad debt or the charity care-indigent category." 5
But that s not all the newfound money coming into the hospital. In addition to reimbursements for specific patient accounts, the Medical Center gets paid for the hospital s disproportionate share of statewide costs for indigent care, based on total Medicaid days. By qualifying more patients for Medicaid, the Medical Center gets increased federal payments. Then there s the more favorable drug prices a hospital can receive for indigent patients. Qualifying additional people for Medicaid helps the Medical Center stay above the threshold level for participating in this program. What s the overall feeling about the UVa Medical Center s partnership with Chamberlin Edmonds? Here s how an article in the University Health System Consortium s newsletter, UHC News, summed it up: "A significant portion of previously designated bad debt or indigent/charity care is now paid in full. Patients maintain their dignity and are usually very willing to assist in the process. Patient Finance, by virtue of the program s success, is a champion and hero among the hospital s business units. The Medical Center s executive leadership are fully on board and supportive of the relationship with Chamberlin Edmonds." One of those supporters is Larry Fitzgerald, the Medical Center s chief financial officer. "Helping patients become eligible for government programs is a necessary duty of every hospital s business office," he said. "The job requires dedication, focus, persistent follow-up and skill in dealing with complex application processes. With the help of Chamberlin Edmonds, we are now excelling in this task. Their efforts have made a positive impact and exceeded our expectations." 6
Michael s story (Background: Chamberlin Edmonds assisted this claimant by filing a Social Security Disability and Medicaid application. We also helped Michael to receive financial assistance from the hospital for medications and bills while his Medicaid application was being processed.) I didn t think I d ever get any assistance. My health got worse because I couldn t afford any medications, and I couldn t get help. I ve been trying to get assistance over the last two years, but I kept getting denied because they said I would have to sell my house to get assistance. Twelve days after Chamberlin Edmonds started working with me, they got that problem fixed. Chamberlin Edmonds always followed through. Anytime they said they would call, they did. They came to my hospital room every day to give me an update on what they had found out. Whenever I had questions, I could always count on Chamberlin Edmonds for fast answers. They helped me get through all of the paperwork and explained every piece of paper and the entire process. No one has ever given me that level of attention before. When I walked out of the hospital, I didn t have any worries at all because I have Chamberlin Edmonds on my side. Having them working for me makes the process easy and I m no longer getting frustrated trying to get assistance. Source: Interview with Zach Douglas Assistant District Manager, Chamberlin Edmonds About Chamberlin Edmonds Headquartered in Atlanta, Georgia, Chamberlin Edmonds serves as patient advocates and provides custom-tailored eligibility services to hospitals nationwide. Our comprehensive services examine the widest spectrum of uninsured and underinsured patients, including inpatient, outpatient and emergency department cases. The advanced technology of our proprietary web-based system is built on the unique experience and expertise of the most qualified eligibility and enrollment professionals in the industry our people. Chamberlin Edmonds has over 25 years of experience in eligibility services, with eight regional offices in the U.S. Please visit www.chamberlinedmonds.com to learn more. Medicaid Eligibility (Inpatient, Outpatient, ED) Social Security Disability - SSDIB Supplemental Security Income - SSI State Disability Charity Care Crime Victims Assistance 800.255.0953 www.chamberlinedmonds.com 03.09.11 FB3945