Help the Uninsured (Without Going Broke)

Herrick points to a strategy at the publicly supported Parkland Health and Hospital System in Dallas—which has the primary responsibility of providing medical care to the indigent of Dallas County—to verify place of residence and sometimes income level to prevent fraud at the hospital. Because Parkland is supported by county taxes, only people who live inside the Dallas County borders can qualify for the hospital's charity program (for those with no payer source). However, hospital administrators began identifying cases of people who came to Parkland from nearby counties and gave false information in an effort to qualify for the charity programs.

In November 2006, the hospital implemented a fraud-detection system, and the hospital district's police staff began working with the district attorney's office to pursue criminal charges against patients who fraudulently received treatment at Parkland. Since then, hospital police have received 481 cases of patients who gave a false address or financial information to avoid payment; the police force has referred 58 cases totaling $1.9 million in lost hospital fees to the DA's office for prosecution, says Lt. Rick Roebuck of the Dallas County Hospital District police force. As of July, the DA's office has achieved 27 convictions resulting in court-ordered restitution of $786,470. "The investigations are ongoing, but now there are safeguards that have been put in place to prevent future fraud. Our intent is to halt fraud altogether, and we think that once people see we are actively pursuing these cases, they will quit attempting to get on the program fraudulently," Roebuck says.

Front-end work
Like healthcare providers everywhere, Orlando Health, the seven-hospital nonprofit system in central Florida, has borne the expense of the double-digit growth of the uninsured. "The cost of charity care alone in fiscal 2007 was $59.2 million. In 2006 it was $49.5 million. So we've seen a significant increase in one year," says Keith Eggert, Orlando Health's vice president of revenue management. "The financing of healthcare basically comes down to a delicate balance of trying to stay ahead at the end of the day with the claims that you actually do get paid on."

Orlando Health, which changed its name from Orlando Regional Healthcare in May, emphasizes front-end strategies to help offset rising costs related to uninsured patients—starting with properly trained staff. One of the first people a patient meets at the hospital is the data-entry clerk, so Orlando Health leaders decided to give their data clerks a more-involved role—that of financial counselor.

"Historically, they were considered very clerical in nature, and in some organizations that classification still exists. We changed the mindset years ago," Eggert says. "Our philosophy is, ‘If I am registering you, it's a face-to-face discussion. It's my opportunity and my job to answer all of your questions and take care of your needs at a one-stop shopping perspective.' We've done away with the attitude of, ‘I'm a clerk. I only intake information and put it into the computer. Someone else will speak with you about your financial counseling needs.'"

New employees take a mandatory six-day training course before they're designated a financial counselor and assigned to a hospital. In addition to quarterly reassessments, Orlando Health uses Registration Quality Improvement to assess the work of its financial counselors. "It's an artificial intelligence system that does 100% quality assurance on every single registration activity in our system every day," Eggert says. "So every single financial counselor gets an accuracy rating every day that is cumulative by the week, by the month, and by the fiscal year."

The system lets Orlando Health monitor the amount of money that every counselor is collecting versus the amount of money they should be collecting. "We have performance statistics for both components: the accuracy of what they are doing, and what are they doing in the way of collecting the dollars at the front door," Eggert says.

The financial counselors try to ascertain how the patients will pay for their care. If the patients are uninsured, the counselors try to determine their eligibility for Medicaid or any state or local charity care options and let those patients know what their payment options are as soon as possible. "For whatever reason, there is a significant portion of the charity-eligible population that never applies for charity—either they don't know how or there is a pride factor involved," Eggert says.

In the emergency department, for example, Orlando Health's financial counselors interview patients and create a demographic at the point of triage, Eggert says. Once the patient is seen by a physician, a counselor returns to the bedside with a wireless device to complete the registration and take down insurance information when applicable or a financial statement if the patient is uninsured.

When the screening is completed, Orlando Health outsources its Medicaid eligibility functions to several companies that follow up with the patient in the hopes of obtaining some Medicaid benefits to defray expenses. If the patient is admitted, the eligibility companies do the screening at the bedside to get the process rolling as soon as possible.

Eggert says collecting money from "tweeners"—those patients who don't qualify for charity care and who also don't have health insurance—is a little more complicated. "We give a 40% discount off a charge across the board to all uninsured patients. But literally that is the population where there is nothing you can do other than establish a payment arrangement or obtain some sort of loans," he says.