It's no secret that border states like Texas, New Mexico and California face unique challenges when it comes to caring for undocumented immigrants. Such states spend billions of dollars each year in administrative and medical care costs for their immigrant populations, and providers say federal assistance has been fleeting. In Texas, the state comptroller's office recently found that $1.3 billion of the $9.2 billion in uncompensated care provided by the state's hospitals in 2004 could be attributed to caring for undocumented immigrants. Under Section 1011 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003, hospitals and some providers are eligible to receive reimbursement for emergency services furnished to immigrants, but collecting that money has proven to be difficult at best for many hospitals. "1011 is a Band-Aid on a gaping wound. It was basically a bone that was thrown our way to help address a mandate. It only covers the first 48 hours of care, but the care that we provide after that stabilization period runs into the billions," says Ron Anderson, M.D., president and chief executive officer of Parkland Health & Hospital System in Dallas.
Collection woesThe main issue hospital administrators say they face in treating undocumented immigrants is collecting payment for services rendered. In an effort to address this burgeoning problem, the federal government agreed to pay $250 million per year for fiscal years 2005 through 2008 directly to providers who submit "qualified claims"-but meeting that standard has proven to be a sticking point for many providers looking to get paid. To qualify for Section 1011 reimbursement, each hospital must fulfill certain eligibility requirements, such as asking patients whether they are eligible for Medicaid, have a border-crossing card and are foreign-born. "Part of the problem with this particular billing system is that the logic that is being used to identify this population is opposite of what we're used to. In this case, we are hunting for the absence of documentation," says Ernie Schmid, policy director at the Texas Hospital Association, which supported passage of the Section 1011 legislation. "And, secondly, there is some fear in hospitals that they are dealing with questions regarding immigration that are inappropriate, and hospitals are very sensitive to their responsibility to protect and care for their patients," he adds.Each hospital trying to obtain reimbursement under Section 1011 has to determine its own method for obtaining the required information from its patients. For Parkland Memorial, that does not include asking its patients directly about their immigration status, but instead training their staff to ask a broader range of questions to help determine eligibility."Some states haven't participated in this program at all because of the criteria where they have to ask nationality. They don't want to be perceived as INS agents. In Texas, we don't want to be INS agents either, but we have to try to get this information," said Anderson.
Education is keyBoth Schmid and Anderson noted that the biggest issue facing rural hospitals trying to obtain Section 1011 funding is a lack of understanding about how to apply for it. The program's fiduciary intermediary, Trailblazer Health, offers training on its Web site on what forms are needed and how to fill them out, says Anderson. "It's a misperception that it's impossible to get this money. Not only is it possible, it's easy once you learn how."The best way rural hospitals can ensure that they are getting the funds available to them is to educate themselves about how to correctly bill the federal government for their Section 1011 patients, adds Schmid. "The most common mistake that hospitals make is not knowing enough about the billing process."
Larger cutParkland is also currently in the process of trying to get the federal government to redirect the money that is not being used by states that are not participating in the Section 1011 program back to states that are billing more than their allotment. "There are 17 states that have not billed anything under 1011. We have asked the federal government to redirect the lapsed money back toward states that are billing and that are facing much higher costs related to this care," says Anderson. For the first six months of 2005, 725-staffed-bed Parkland submitted claims to the federal government that totaled $1.984 million, and it received $1.1 million in payments. For the second and third quarters, the hospital received far less in payments even though it billed more because, according to Anderson, more hospitals began participating in the program, diluting the state's total allotment of $56 million per year. "In September we billed $2.94 million and we got $664,000. At the end of the second quarter of our last billing, we billed $2.547 million, and we got $523,389," says Anderson. So far, providers in Texas have submitted claims totaling $65.4 million to the federal government, according to figures from the Texas Hospital Association, and have received payments of approximately $14.3 million.
-Kathryn Mackenzie
Magazine
