Eligibility screening a tourniquet for EDs

June 2, 2010

Due to uncompensated care, many hospitals are losing money from their emergency departments (EDs). Eligibility screening can help reverse the trend.

Mary Tackbary

Many uninsured patients do not know that they may qualify for a range of public and private healthcare programs. Screening ED patients to determine health-insurance eligibility for programs, such as Medicaid, and facilitating a patient's application to these programs, can provide hospitals with funds to cover otherwise uncompensated care. Allocating the necessary levels of staff and finances to address eligibility, however, is often not economically feasible — and will become less so in three years, when healthcare reform mandates take effect.

Responding to these factors, hospitals should develop processes and procedures that reassure patients about the availability of care while simultaneously seeking their cooperation in investigating benefits that provide reimbursement for hospital services.

The problem is particularly acute with ED services. According to the California Health Care Foundation, treatment in an ED is three to four times more expensive than comparable care from a doctor's office. Because the uninsured use the emergency room for treatment that could be administered by a primary care physician — a study by the California Health Care Association found 46 percent of ED users believe their primary doctor could have handled their condition — this behavior results in hospitals absorbing millions in uncompensated costs.

The financial burden of the uninsured places hospitals in a difficult position: Their commitment to patients, as well as legislative mandates, compels them to deliver care. Yet they need to help patients explore possible coverage to ensure organizational solvency.

In addition to discomfort about approaching patients for payment, the ED is a busy place with financial constraints. Because EDs operate 24 hours, seven days a week, scheduling additional staff to screen patients for payment is not a viable option for many hospitals.

Fortunately, approximately 25 percent of the uninsured are eligible for some sort of public coverage, although most eligible patients do not realize they qualify.

Screening patients during their ED visit is an effective approach to discovering if they qualify for any government medical plan, auto accident coverage or crime victim programs. But while this approach is promising, only 5 to 10 percent of hospitals typically conduct screening at the time of service while the patient is on hand to supply all necessary information.

With eligibility screening software, between 75 and 80 percent of patients can be screened without increasing the number of hospital staff — a substantial increase from the estimated 5 percent of patients that are currently screened. A hospital staff member follows an interactive questionnaire to determine patient eligibility for Medicaid and other government programs. Patients answer questions that are adjusted according to their responses — ensuring individuals can be fully screened with a few brief questions.

Hospitals are able to assist the greatest number of patients with minimal strain on human resources by seeking tools that require minimal training and guiding each user through the process. This removes the burden of ensuring staff members charged with screening activities are intimately familiar with all the nooks and crannies of public programs. Computer “prompts” assist users with the questions they need to pose to patients; this ultimately leads to the coverage — whether provided by the state or federal government or charity organizations — for which the patient is a match. This enables an organization to protect its bottom line through providing coverage for the uninsured, while lifting the screening burden from overworked staff members.

Once eligibility has been determined, the enrollment process needs to be initiated. In many cases, enrollment is extremely time consuming — the application for Medicaid requires approximately 60 pages of information, for example. The best software solutions ensure data collected during screening can be used to auto-populate coverage application fields — accelerating and simplifying the application process.

Integration with existing administrative systems is also a plus. During the screening process, for example, notifications can be set by registration staff to alert financial services personnel that benefits are being sought for a patient who has been admitted as self-pay but who actually may be eligible for coverage.

Web-based functionality also improves the efficacy of screening tools. Information used to assess patient eligibility is most likely to be up-to-date, because changes in requirements and regulations across multiple programs can be tracked at the central server site — rather than requiring individual software programs to be updated. In addition, Web access allows multiple users across the organization to make use of the screening date, particularly relevant should the patient be transferred from the ED to any in-patient department.

Information contained within the product's database can also be used for analytical purposes, giving staff the ability to monitor, track and report key metrics on patients and processes so that staff can focus on areas needing improvement. Most eligibility software also has the ability to follow cases to resolution and optimize reimbursement.

Facilitating the eligibility screening process is a win-win situation for both hospitals and patients: When coverage can be secured for uninsured patients, the hospital plugs a financial drain. Hospitals incorporating eligibility screening programs have reported the number of patients able to acquire coverage has doubled. This is even more financially relevant when the newly eligible patient has outstanding medical bills, since certain programs, such as Medicaid, can be retroactively applied for up to three months.

Patients benefit as well, taking their coverage with them once enrolled. Not only is the care they receive in the ED covered, but coverage will follow them beyond the immediate encounter. This increases the odds that patients will get the follow-up care and routine check-ups they need, which diminishes the future burden on the ED.

Hospitals will most likely continue to carry some burden of uninsured ED patients. To maintain quality of care, balanced with financial sustainability, solutions should be sought to improve this situation. New technology can be intimidating, but proven eligibility-screening software solutions are user-friendly, and require only a computer and an Internet connection. Staff may not only save money, they may save time, which can be better spent on caring
for patients.

Mary Tackbary is vice president of new markets for Chamberlin Edmonds, an eligibility and enrollment services firm that works with hospitals and their patients to secure reimbursement for potential uncompensated care. For more information on Chamberlin Edmonds solutions: www.rsleads.com/006ht-201

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