Community benefit raising the bar through people partnerships and technology
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Community Benefit: Raising the Bar through People, Partnerships and Technology. UPMC Patient Financial Services Center April Langford MedAssets Julie Kay. Overview. Objectives Community Benefit: The industry status About UPMC Environmental conditions Identifying the need

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Community benefit raising the bar through people partnerships and technology

Community Benefit: Raising the Bar through People, Partnerships and Technology

UPMC Patient Financial Services Center

April Langford

MedAssets

Julie Kay


Overview
Overview

  • Objectives

  • Community Benefit: The industry status

  • About UPMC

    • Environmental conditions

    • Identifying the need

    • Key indications

    • Executing Action

    • Process, Technology and Partnerships

    • Current outcomes

    • Lessons Learned

  • Final thoughts


Objectives
Objectives

  • Understand how UPMC confronted their Community Benefit initiatives

  • Identify innovative and creative ways for performing community-focused initiatives

  • Learn how technology and improved processes can impact community outreach.


Community benefit industry status
Community Benefit: Industry Status

  • Patient Protection and Affordable Care Act (PPACA)

    • Community Health Needs Assessment

    • Financial Assistance Policy

  • Tax Exempt Status Threatened

  • Patient Financial Management

    • Social Service vs. Collection Effort

    • Detailing Program Practices

    • Identifying Outcomes

    • Sharing the impact with the Community


About upmc
About UPMC

  • Integrated global healthcare enterprise headquartered in Pittsburgh

  • One of the largest non-profit health systems in the nation

    • Hospital and Community Services – 20 tertiary , community and specialty (Psychiatric, Women’s Children’s) hospitals, 400 outpatient sites

    • Physician– nearly 5,000 physicians with privileges at UPMC hospitals, including more than 3,000 employed

    • Insurance – UPMC Health Plan has over 1.6 million members and covers commercial, Medicare Medicaid, CHIP, behavioral health, employee assistance and workers’ compensation segments

    • International and Commercial Services – exporting knowledge and expertise internationally with footprints in Italy, Ireland, China, and Japan

  • Transformed the economic landscape in Western Pennsylvania

    • 54,000 employees; largest employer in Pittsburgh


  • The UPMC Corporate Revenue Cycle (CRC) manages all facilities in an integrated model

    FY11 Results:

    • Net Patient Service Revenue $4.1B

    • Annual Cash Collections$4.1B

    • Annual Claims Processed 4.2M

    • Clean Claims 92.5%

    • Average Days in AR34

    • % A/R >90 Days 5.7%

    • Denials 0.8%

    • Denial Direct Write-Offs 0.1%

    • Uncompensated Care to Gross Revenue 2.63%

    • FTEs 378

    • Average Revenue per FTE $10.87M


Upmc patient financial services center
UPMC Patient Financial Services Center

The UPMC Patient Financial Services Center was designed to assist uninsured and underinsured individuals and families in finding financial solutions for medically necessary services.

We developed our Patient Financial Services Center such that caregivers and patients can access financial services and counseling throughout the entire continuum of care.


Upmc patient financial services center identification of need
UPMC Patient Financial Services Center:Identification of Need

  • National Indicators*:

  • Beginning in 2014, the American Recovery and Reinvestment Act will extend MA eligibility to all Americans under age 65 whose family income is at or below 133% of federal poverty guidelines.

  • PA State Indicators**:

    • Pennsylvania’s uninsured population showed an increase in the past year from 9.7% to 11% of the overall population.

    • UPMC Specific Indicators:

  • Increasing Self Pay Population and Patient Balances

  • Increasing Uncompensated Care

    • Uninsured/underinsured individuals may not be aware of programs designed to provide financial assistance.

  • *http://www.ncsl.org/issues-research/health/medicaid-home-page.aspx

    • **2011 America's Health Rankings® by the United Health Foundation


Uninsured population of pennsylvania

UPMC Patient Financial Services Center:Identification of Need – PA State Indicators

Uninsured Population of Pennsylvania

Data taken from 1990-2011 America's Health Rankings® by the United Health Foundation.


Upmc patient financial services center identification of need upmc specific indicators
UPMC Patient Financial Services Center:Identification of Need – UPMC Specific Indicators

39% Increase since FY09


Upmc patient financial services center identification of need upmc specific indicators1
UPMC Patient Financial Services Center:Identification of Need – UPMC Specific Indicators

18% Increase since FY09


Upmc patient financial services center identification of need upmc specific indicators2
UPMC Patient Financial Services Center:Identification of Need – UPMC Specific Indicators


Upmc patient financial services center positive outcomes
UPMC Patient Financial Services Center:Positive Outcomes

  • Patient qualifies for Medical Assistance

  • Patient qualifies for UPMC Financial Assistance

  • Patient obtains other funding from programs such as:

    • Victims of Violent Crimes

    • Leukemia & Lymphoma society

    • National Breast and Cervical Cancer Early Detection Program

  • Cash collection increases as patients qualify for external funding

  • Cash collection increases as patients make payments

  • Affordable and manageable payment plans are set up

  • Individual’s credit rating is protected from bad debt collection efforts


Upmc patient financial services center negative outcome
UPMC Patient Financial Services Center:Negative Outcome

  • Patient sent to Bad Debt due to inability to pay


Upmc patient financial services center1
UPMC Patient Financial Services Center

Referrals to the UPMC PFSC occur along the entire continuum of care, and a proactive approach is taken to ensure that all uninsured/underinsured patients are identified as soon as possible.

Primary Initiatives

Points of Referral

Obtain MA for Patient

Pre Arrival

Provide Financial Assistance for Qualified Patients

UPMC

PFSC

Point of Service

Create Effective Collection Process

Post Service

After the patient is referred to the UPMC PFSC, a specialist will work with the patient to determine if they qualify for Medical Assistance, Financial Assistance or have the ability to pay. They will then work with the patient to assist in the application process and/or set up a mutually agreeable payment plan.


Proactive identification of uninsured underinsured patients and patient responsibility workflow
Proactive Identification of Uninsured/Underinsured Patients and Patient Responsibility - Workflow

  • Early identification of individuals with financial need enables us to properly refer patients to the appropriate financial services program.

  • Uninsured/Underinsured patients are identified in our pre-arrival center via our ePayer Insurance Verification and Self-Pay worklists. Onsite Case Managers or Social Workers identify uninsured/underinsured patients presenting to sites and call or email the UPMC PFSC to notify specialists of the patient’s financial situation.

  • If patients are unable to pay, co-payments, coinsurance and any other outstanding patient balances at the point of service, referrals to the PFSC are initiated. UPMC PFSC specialists reach out to the patient and work with them to pursue program/payment options.

    • The goal is to reduce “Elective” Bad Debt and to minimize financial risk to UPMC and the patient.


  • Proactive identification of uninsured underinsured patients and patient responsibility technology
    Proactive Identification of Uninsured/Underinsured Patients and Patient Responsibility - Technology

    • The UPMC eEligibility electronic Insurance Verification system identifies patient responsibility pre-arrival and automatically posts patient responsibility into the patient accounting system for collection at point of service.

    • Our UPMC Self-Pay electronic worklist identifies uninsured/underinsured patients prior to service . We can then reach out to patients and initiate steps to secure payment and/or initiate financial counseling.

    • Criteria for qualification to the UPMC PFSC Self-Pay Electronic Worklist:

    • All Uninsured patients are automatically added to the worklist

    • All Auto patients are automatically added to the worklist

    • Underinsured patients are referred from the pre-arrival insurance verification worklistvia a transfer button

      • Workers’ Compensation with no Secondary Insurance

      • Medicare Part A Inpatients with no Secondary Insurance


    Proactive identification of uninsured underinsured patients and patient responsibility outcomes
    Proactive Identification of Uninsured/Underinsured Patients and Patient Responsibility - Outcomes

    Pre Arrival Uninsured/Underinsured SDS and Outpatient Radiology - Combined

    • Insurance Coverage Identified 59%

    • Referred to UPMC PFSC 41%

      • MA Eligibility Approved / Pending 55%

      • Financial Assistance Approved / Pending 24%

      • On-Going Internal Collection Process 18%

      • Payment Collected 3%


    Proactive Identification of Uninsured/Underinsured Patients and Patient Responsibility - Outcomes

    37% Decrease since Nov 10

    Non-Emergent Uncompensated Care as a Percentage of Total Uncompensated Care


    Proactive Identification of Uninsured/Underinsured Patients and Patient Responsibility - Outcomes

    • ePayer automatically gets Patient Responsibility information from Payer Portals and posts it into the patient accounting (PA) system for POS collections

    • Collection efforts are tailored based upon Propensity to Pay Segmentation posted in PA System

    • Scripting is provided to Registrars for various scenarios

    • Patients who cannot pay are referred to the UPMC PFSC via phone, email, fax, and documentation in the PA system.

    219% Increase since Feb 2010


    Medical assistance eligibility workflow
    Medical Assistance Eligibility - Workflow and Patient

    • Determining a patient’s eligibility for alternative coverage sources is a major piece of the UPMC PFSC workflow.

    • We start the process with evaluating the patient’s eligibility for their state Medical Assistance Program. Most states have a 90 day retroactive eligibility period so it is crucial to identify potentially eligible patients quickly.

    • We use 5 selected vendors to assist Inpatients during the Medical Assistance application process

    • We created an internal Medical Assistance Eligibility team to assist Outpatients during the Medical Assistance application process.


    Medical assistance eligibility workflow1
    Medical Assistance Eligibility - Workflow and Patient

    • Uninsured patients are provided with a specialist to facilitate the Medical Assistance application process.

    • Specialists complete and submit the Medical Assistance application on behalf of patient and act as a liaison with the Medical Assistance office to attempt to gain eligibility for the patient.

    • The process ensures that applications are submitted quickly and completely.

    • Specialists assist patients throughout the entire application process. They follow up with the Medical Assistance office and the patient to verify that all documentation is submitted.

    • UPMC’s Medical Assistance eligibility work tool (eMA) monitors this process, both internally and externally, ensuring that applications are processed in a timely fashion and that thorough follow-up is completed.


    Medical assistance eligibility technology
    Medical Assistance Eligibility - Technology and Patient

    • eMA – Medical Assistance Eligibility Worktool

    • eMA actively identifies uninsured/underinsured patients and ensures appropriate follow up during the MA eligibility process.

    • eMAalso identifies individuals who have been eligible for medical assistance within the past two years, pregnant women, and children with chronic illnesses and automatically adds them to the worklist for contact and financial counseling.

    • eMA enables Medical Assistance specialists to contact patients prior to or quickly after their service, to increase the likelihood of eligibility.

    • eMAhighlights the status of the account in the eligibility process, enabling Medical Assistance specialists to easily track individual accounts and initiate data driven process improvement efforts to expedite eligibility.


    Medical assistance eligibility technology1
    Medical Assistance Eligibility - Technology and Patient

    • eMA – Medical Assistance Eligibility Worktool


    Medical assistance eligibility technology2
    Medical Assistance Eligibility - Technology and Patient

    • eMA – Medical Assistance Eligibility Worktool



    Medical assistance eligibility outcomes1
    Medical Assistance Eligibility - Outcomes and Patient

    Started Internal MA Process

    Changed Referral Criteria to EXCLUDE Balances <$1000


    Medical assistance eligibility outcomes2
    Medical Assistance Eligibility - Outcomes and Patient

    $50,507,572 in MA cash was received

    7,303 patients, or 64%, were approved for MA

    Results of MA Eligibility Process

    In FY11, we referred 11,522 Patients* to MA

    Of those 11,440 closed applications for patients referred to MA…

    7.28% Cash**

    MA APPROVED

    85.72% FA W/Os

    2,144 patients, or 52% were denied as Over Income

    MA DENIED

    7.00% BD W/Os

    Positive Close

    4,137 patients, or 36%, were denied MA. Of those denied MA…

    9.02% Cash**

    1,993 patients, or 48% were denied as Uncooperative

    83.86% FA W/Os

    *Includes IP and OP Referrals

    **Includes Patient, Insurance, and Out for Collection Payments

    Negative Close

    7.12% BD W/Os


    Upmc financial assistance eligibility workflow
    UPMC Financial Assistance Eligibility - Workflow and Patient

    • As soon as we determine if an uninsured/underinsured patient is not eligible for Medical Assistance, we evaluate the patient for the UPMC Financial Assistance program.

    • UPMC PFSC Specialists work with the patients to complete the application and collect all required documentation necessary to make a determination for financial assistance.

    • By helping the patients navigate this process, we are able to ensure that all qualifying patients are able to get necessary financial help.


    Upmc financial assistance eligibility workflow1
    UPMC Financial Assistance Eligibility - Workflow and Patient

    • Patients may be eligible for UPMC Financial Assistance for medically necessary services if they:

      • Have limited or no health insurance

      • Can demonstrate financial need

      • Provide UPMC with necessary information about household finances

    • Financial assistance is not available for:

      • Insurance co-pays (excluded unless the co-pay balance is a hardship)

    • Financial assistance is typically not available for:

      • Deductibles

      • When a person fails to comply reasonably with insurance requirements (such as obtaining authorizations and/or referrals)

      • For persons who opt out of available insurance coverage

      • International patients



    Upmc financial assistance eligibility outcomes
    UPMC Financial Assistance Eligibility - Outcomes and Patient

    Over 200 More Applications Received per Month in FY 12 than FY11


    Upmc financial assistance eligibility technology
    UPMC Financial Assistance Eligibility - Technology and Patient

    • eFA– Financial Assistance Eligibility Worktool


    Upmc financial assistance eligibility technology1
    UPMC Financial Assistance Eligibility - Technology and Patient

    • eFA– Financial Assistance Eligibility Worktool



    Identification of patient ability to pay workflow self pay segmentation
    Identification of Patient Ability to Pay – Workflow and Patient Self-Pay Segmentation

    • When the patient enters our Self-Pay automated predicative dialer system for collections, they are immediately segmented into one of 6 segments, directing the workflow of the collection process.

  • We strive to prevent patients who have the ability to pay from being referred to bad debt at all costs. We work with patients to explore every avenue to obtain payment from alternative coverage sources and set up affordable payment plans.


  • Identification of patient ability to pay workflow self pay segmentation1
    Identification of Patient Ability to Pay – Workflow and Patient Self-Pay Segmentation

    • Segment 1: High Propensity – Previous Payment at UPMC or Collection Agency

    • Segment 2: Medium Propensity – New Patient or Patient on Payment Plan

    • Segment 3: Low Propensity – No Payment History at UPMC or Collection Agency

    • Segment 4: All Balances < $100

    • Segment 5: Financial Assistance – Approved w/o Application

    • Segment 6: Financial Assistance – Approved w/ Application or Currently Applying


    Identification of patient ability to pay outcomes self pay segmentation
    Identification of Patient Ability to Pay – Outcomes and Patient Self-Pay Segmentation

    15.57% of referrals to UPMC PFSC are identified through scoring





    Upmc patient financial services center self pay outcomes
    UPMC Patient Financial Services Center: and Patient Self-Pay - Outcomes

    UPMC PSFC Opportunity – Bad Debt


    Upmc patient financial services center essential partnerships
    UPMC Patient Financial Services Center: and Patient Essential Partnerships

    • The presented outcomes would be impossible to achieve without effective and mutually beneficial partnerships with the following:

    • Patient Access – Insurance Verifiers

    • On-Site Staff – Registrars, Case Managers, Social Workers

    • UPMC PFSC Specialists

    • Vendors

    • County/State MA Office

    • CFOs and other Operational Leaders

    • And most of all,

    • Our Patients


    Overall results
    Overall and Patient Results


    Final thoughts
    Final Thoughts and Patient


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