Creating a Comprehensive Assistance Program for uninsured/underinsured

1. Creating a Comprehensive Assistance Program for uninsured/underinsured AAHAM November 2010

2. Increased Revenue Cycle Technology = Greater ROI and Added Jobs: The BayCare Health System Story Lou Ann Watson Medical Assistance Manager BayCare Health System

3. BayCare Health System • Mission: • To improve the health of all we serve through community-based healthcare services that set the standard for high-quality, compassionate care Community-based healthcare system in the Tampa Bay area *Ambulatory Care Division surgery, imaging, wellness access points **Includes endoscopy+ 2009 billable tests^Unreimbursed costs for traditional charity care, Medicaid and county welfare programs, indigent care fund payments and unbilled community services in 2009.

4. BayCare Health System • Member hospitals formed in 1997 under a common mission and shared values • Private, non-profit • Specialty Hospitals - Children’s, Women’s, Trauma, LTACH • Behavioral Health and Rehab Services • Unique patient populationsand hospital identities “As an organization, our mission is to improve the health of all we serve, regardless of their ability to pay.“ ~Steve Mason, CEO, BayCare Health System “

5. BayCare Approach to the Uninsured • Established a health system-based Medical Assistance Program to support uninsured, underinsured and non-citizen patients in 1999 PURPOSE Increase access to community-based healthcare for at risk patients and ensure their ability to obtain financial assistance for health care expenses Financial concerns should not deter anyone form seeking medical care Committed to serving community residents with compassion and dignity regardless of their ability to pay Do the right thing for the patient…every time GUIDING PRINCIPLES

6. Why a Health System Based Program Ensures our culture and our values High visibility as a corporate directed and managed department Patients seen regardless of financial outcome Team members easily move between hospitals Follows our compliance program Very low cost to collect Low turnover and easier to train Health system experts for uninsured issues Addresses Mission and Fiscal Responsibility

7. Help patients and families access assistance for health care through community, state, and federal programs Advocacy, education and support are emphasized in a patient-focused, social work approach Patient outreach in conjunction with strong community partnerships ensures successful outcomes for patients and a financial benefit to the hospital Medicaid Florida KidCare Payment of COBRA premiums County Health Care Plans Medical Assistance Programs HCRA BayCare Hardship Charity Victim’s Compensation AHCA Charity The Medical Assistance Team

8. A Patient Centered Process • Conduct interviews at the time of service – inpatients at the bedside, in the emergency room, and pre- and post-service All hospital accounts included for assistance Financial assistance screening and application submission for uninsured and underinsured patients Current and future needs met Education and support provided through final disposition to patients and families

9. Florida Unemployment • The economy has an immediate impact on patients’ ability to pay – experienced a 38% increase from Jan 2009 – Jan 2010

10. Florida Uninsured Rate – 21% • Average percent uninsured by state 2006 – 2008 • Florida ranks 3rd in the nation in uninsured • 2nd highest % of uninsured children • 26.6% under 65 are uninsured • More uninsured than Medicare eligibles • Uninsured rate is up 40% since 2000 Source: US Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States: 2008. Data released August 2009. Link: http://www.census.gov/hhes/www/hlthins/hlthin08/hlthtables08.html. *The Uninsured: A Closer Look, Families USA, March 2009

11. Challenges in Our Community • Increased number of uninsured patients entering our emergency rooms and unable to pay for services • Economy worsened in 2009 causing layoffs • Uninsured patients have difficulty accessing the health care system outside of the ER for primary care needs • Uninsured in our area runs between 19% - 21% • Service industry and “young” retirees • Significant undocumented populations • Existing process had reached a plateau

12. A Need to Expand and Embrace Technology • Maximize health system control of growing uninsured population • Address patients accessing health system’s many doors for help • See more patients – particularly in the ER • Lessen paper and manual processes • Increase productivity, accountability and standardization • Appropriately identify patients eligible for charity and community programs – state and federal requirements “We cannot become what we need to be by remaining what we are.” ~Max Dupree

13. Opportunities for Expansion • Children are a priority and can be easily covered • A portion of the population will qualify for Medicaid or other insurance coverage • Future benefit — Medicaid patients return 2 or more times for service • Once insured, patients can access physicians, etc. • Potential reimbursements from charity

14. The Program: ERMA Implemented in April, 2009 20 positions added WOWs – workstations on wheels ER patient interviews – 7 days a week, 12-15 hours per day “Missed” inpatients caught (weekend and short stays) The Tool: TransUnion Revenue Manager Interview tool for all team members Integrated process from beginning to end Centralized patient information Allows for partnerships with community agencies and grant programs Emergency Room Medical Assistance

15. Revenue Cycle technology • Incorporated external demographic and financial data into front-end processes • Verifies patient identity and eligibility for financial assistance at the time of registration • Provides real time alert messages to financial counselors • Ensures data accuracy • Simplifies the eligibility determination process • Matches patients and families to the right programs • Automates the application process • Collaborating with Medicaid for direct submission

16. Factors for Success • Everyone involved • Consistent approach • Cross-functional training • Measurable accountabilities • Map current and desired processes • Continual refinement • Align people to processes • Identify key owners / sponsors

17. Patient satisfaction and peace of mind Treatment continuity in the community Direct patients to more appropriate community-based healthcare Decreased return mail Charity versus bad debt System data base to continually monitor & profile our populations Additional financial gains Decreased collection agency (health system-owned) costs Patient, Hospital and Community Benefit • Reimbursement for all providers

18. Applied Programs 5,811 patients 7,864 patients

19. ER Patient Population

20. Effect on our population ofchildren coming into the ED Average Variance 3%

21. ER Charity & Bad Debt

22. Health System Charity and Bad Debt

23. Bad Debt, Charity & Self Pay to Gross Revenue

24. ER Upfront Collections

25. Medical Assistance Collections

26. Ongoing Considerations • Maximization of Charity and Medicaid Eligibility • Healthcare Reform • Non profit status – IRS Form 990 disclosures, annual cost report disclosures • Transparency – discount and charity policies • Medicaid eligibility expansion in 2014 • LIP – Low Income Pool (Florida) • Exemptions from Medicaid limits so hospitals are paid based upon costs/allocations additional funding driven off Medicaid, charity and 50% of bad debt • HITECH • Payments for implementation of an electronic medical record/meaningful use are impacted by a hospital’s charity in relation to total charges. This definition of charity is the federal definition which reverts back to the hospital’s policy.

27. Next Steps • Ensure more patients are reached • Maximize outcomes for each hospital • If North Bay Hospital were to meet the 11% threshold of Medicaid/charity utilization, the increase in Medicaid reimbursement would be about $1.2-$1.4M • Presumptive eligibility process • Involve more community partners in the process • Continuous improvement and reporting

28. Strapping New Technology on Old Business Will Not Propel You in the Right Direction Questions and Discussion

29. Contact Information • Lou Ann Watson, CPAM • Manager of Medical Assistance • BayCare Health System • Office: (727) 709-6083 • LouAnn.watson@baycare.org • www.baycare.org