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Eligibility screening a tourniquet for EDs

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

By 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 uncom- pensated care. Allocating the necessary levels of staff and fi nances 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 benefi ts that provide reim- bursement 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 offi ce. 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 fi nancial burden of the uninsured places hospitals

in a diffi cult 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 fi nancial con- straints. 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

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June 2010

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 Med- icaid 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 seek- ing 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 Med- icaid 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 fi elds – accelerating and simplifying the application process.

Integration with existing administrative systems is also a plus. During the screening process, for example, notifi cations can be set by registration staff to alert fi - nancial services personnel that benefi ts are being sought for a patient who has been admitted as self-pay but who

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