"At the end of the day, the basic situation hospitals find themselves in is being mandated to give care long before they know whether they will be compensated," says Brechbühl. "Time has proven that the best approach is to be very proactive—ideally before the patient receives treatment."
Carol McDonald, the vice president of patient financial services at 651-staffed-bed Albany (NY) Medical Center, an academic, urban, Level I trauma center, has spent a lot of time and effort trying to figure out such proactive, tailored solutions—difficult given the variety of uninsured patients that are her responsibility, as well as the variety of public assistance programs and their unique eligibility rules.
"We've had a fairly large indigent population for many years. If you've got it, you tend to figure out how to mitigate it very quickly," she says, adding that "There are significant resources going toward meeting the needs of this population."
One option is to refer patients to the hospital's self-funded charity care program. But with limited resources, she and her team have to make every effort to exhaust other payment opportunities from social service agencies as well as the state Medicaid program.
"We really have a very broad group of players with an algorithm about how we identify and roll out the right program to the patient," she says.
A lot of effort is spent as early as possible. Especially with nonemergent cases, AMC seeks to get patients eligible prior to their procedure and makes an effort to educate patients about the financial process, ease their minds about how their care will be paid for, and explain their responsibilities, if any, in the process. Plus, it makes the billing process a lot smoother to have a patient prequalified.
"The last thing you want to do is send a patient a bill and say, 'Three months ago, you could've applied for this or that program. Too bad, now you owe me all this money.' That's just not going to work."
McDonald and her team have arrived at a variety of solutions that funnel patients to the proper person who can help.
For instance, AMC worked out agreements with three local social services departments and has been designated in nine primary counties to administer financial aid and charity care. A combination of staff, which includes a senior Medicaid examiner, a contract with Chamberlin Edmonds, and AMC case management personnel makes sure the proper applications are filed so that patients can receive aid after discharge and will be eligible if they have to come back to the hospital or any community entity. It's all part of a broader strategy of working on the continuum of care for all patients, but it results in a more cohesive patient payment and care strategy as well.
This method of segmenting the population for tailored payment interventions has paid off. In 2011, AMC collected more than $12.5 million that would likely have been classified as uncompensated care. That resulted from segmenting probable qualified patients to get those consultations. Of 1,427 patients receiving care who were referred to the program, 477 were accepted for both federal and state coverage for their care. Many of those not approved due to eligibility issues received some assistance from the hospital or other sources.
Some of the internal application programs have also helped in less tangible ways, McDonald explains, in improving the hospital's relationship with the patient.
"It's a more friendly environment. Many of our patients, certainly over the past few years, were folks who have always been able to fend for themselves," she says. "There's a certain sense of pride when one does not have to stand in line at the department of social services."
This article appears in the May 2012 issue of HealthLeaders magazine.