Automation is the Key to Efficient Health Care Reform

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act (PPACA) into law, expanding Medicaid and forming health insurance exchanges. The goal of the bill is for all Americans to have access to some form of medical coverage.   Medicaid is expected to play a major role in covering more uninsured people and providing eligibility to nearly all people under age 65 with income up to 133 percent of the federal poverty level (FPL). Medicaid, along with its smaller companion program, the Children’s Health Insurance Program (CHIP), is expected to cover an additional 16 million people by 2019.  Health insurance exchanges are to be formed by 2014 to help insurers comply with consumer protections, compete in cost-efficient ways, and to facilitate the expansion of insurance coverage to more people. However, both government programs, Medicaid and the Government-Sponsored Enterprises (GSE), will have to coordinate in some way with each other.

A great deal of the burden in the coordination and enrollment of these programs will fall on the states.  According to the Kaiser Commission on Medicaid and the Uninsured, it is commonly understood that “given the expected new demands on Medicaid eligibility and enrollment systems, and continuing fiscal strains on states, the impetus to streamline and automate Medicaid systems has never been greater.” Many believe this task will be difficult for states to execute. U.S. hospitals expect a $155 billion reduction in Medicare and Medicaid funding over the next decade as a result of the PPACA’s cost for health care reform. Disproportionate Share Hospitals will be affected more so than most since they receive a significant portion at a higher rate of reimbursement for services that treat more uninsured than insured. The Center of Budget and Policy Priorities found that 48 states had budget short falls in 2009 and 2010, and estimates that 46 states will continue to have budget shortfalls in the following year, which places the States’ ability to provide matching funds in question. With budgets decreasing, unemployment and Medicaid eligible patients increasing, and health insurance exchanges forming, how do hospitals continue to assist their patients and ensure the fiscal health of the hospital?

Douglas Elmendorf, head of the Congressional Budget Office (CBO), recently remarked in a letter to Senator Max Baucus, Chairman of the Senate Finance Committee, that one of the greatest difficulties in enrolling people who are eligible for government programs is the application process itself. One solution he saw was to create a more “efficient enrollment process.”  Elmendorf indicated that an additional 14 million people would become eligible for Medicaid and CHIP under the new PPACA guidelines. Even if states accomplish the goal of streamlining and automating Medicaid systems, it does not mean that patients will actively seek out and enroll themselves. Since there will be more Medicaid-eligible patients than ever before, hospitals will require a process that will quickly screen and fill out all the extensive paper work in order to expedite and secure approval for Medicaid and other programs.

Individuals won’t be registered for these programs and taking advantage of their benefits until they find themselves in need of it, sick in the hospital. The car insurance industry has shown us that just because the state mandates auto insurance does not mean every driver has it. Often times, an accident will have to occur before an uninsured motorist looks to find insurance. In order for the hospital to gain reimbursement, it will have to educate patients on their options, and assist them with their enrollment in Medicaid, insurance exchanges, or other available programs. The verification of information will also have greater importance as the PPACA established the new IRS Code Section 501(r), which requires hospitals to take action and confirm if a patient is eligible for financial assistance, and states look to implement investigations similar to (Recovery Audit Contractor) RAC audits on Medicare. The Washington Post recently published an article on North Carolina’s hiring of IBM to review the past six years of Medicaid data for questionable payments. Now more than ever, the burden of proof is being placed at the feet of the hospital, not the patient.

In their executive summary titled “Optimizing Medicaid Enrollment: Perspectives on Strengthening Medicaid’s Reach under Health Care Reform,” Julia Paradise of the Kaiser Commission on Medicaid and the Uninsured and Michael Perry of Lake Research Partners, found and suggested “it is appropriate for CMS to spearhead automation efforts by developing model enrollment systems for states and providing technical assistance and incentives to promote their adoption.”  Whether or not the states will be able to accomplish this remains to be seen, whereas hospitals are afforded a better chance of success on the front lines of patient interaction and care and have a major incentive to assist patients in enrollment than the state. The only way hospitals can handle the volume of necessary enrollment while driving down costs is through automation.

In doing this, hospitals keep with best practices, and all patients are screened for multiple programs at once with the same questions, which eliminates the possibility of repetition and other forms of human error. Automation also enables providers to maximize staff time and efforts, and allow the service to be offered in outpatient areas. Programs with integrated calculators can compute spend-down requirements, as well as insurance exchanges enrollment fees by the 2014 PPACA deadline. All of this information is kept on file for report generation and the IRS 990, which will also eliminate duplicate applications in multi-system hospitals. At the end of the interview, the tool will bring forth the completed application for the best program the patient is eligible for, any necessary attachments, an electronic signature, and the documents required by the state for eligibility determination, such as electronic pay stubs and tax return information.  By being electronic, the application is then capable of being submitted online, or by facsimile, with tracking information returned to the hospital.

If the goal of Healthcare Reform is for all Americans to have access to some form of medical coverage, then hospitals will need to play the largest role in assisting people towards the proper access channel and the appropriate form of eligibility. Hospitals are in the unique position of seeing patients when they will need coverage the most: at the time of care. The PPACA does offer some direction in terms of an approach to handle the millions of newly eligible patients, but the guidance does not provide the means to properly assist the millions more currently now eligible or eligible-but-not enrolled. Unfortunately, the current state of the economy means hospitals will have to do more with less, and assist a greater number of uninsured patients. Automation will be the key component at the state level (as laid out in the PPACA), and also for hospitals to handle the Medicaid increase and maximize their reimbursement across a variety of repayment options.

Christopher Thunder is a policy analyst and writer for R&B Solutions, a Medicaid Advocacy company headquartered in Waukegan, Illinois.

Ryan Brebner is Manager of Business Development for R&B Solutions, and is responsible for leading the company’s sales and marketing. Ryan is an active member of HFMA, AAHAM, and NAHAM. Ryan graduated from Saint Norbert College in DePere, Wisconsin with a Bachelor of Arts in Politics and Philosophy. For further information, Ryan Brebner can be reached at 847-887-8514.

About R&B Solutions (www.randbsolutions.com)
R&B Solutions is a leading Medicaid Advocacy corporation that both uninsured patients and medical providers alike have come to trust to solve many of the problems facing uninsured patients and the medical facilities from which they seek help. R&B Solutions offers a wide variety of solutions for medical providers to assist their patients. The company uses highly-trained patient advocates efficient in State Human Services processes, internally developed software, and years of legal experience to identify and assist the uninsured. R&B Solutions offers expertise in the field of Medicaid Advocacy (inpatient solution), Solutions for Uninsured Patients (SUP), outpatient solutions, and RAMP (Rapid Application for Medical Programs), proprietary software that screens for Medicaid and charity eligibility. Founded in 1986, R&B assists health care providers and their uninsured patients across the United States.