Eligibility programs are a critical step in the hospital revenue cycle process. That’s because the cost of not optimizing eligibility efforts is dramatic. It can result in suboptimal support for vulnerable populations, as well as uncompensated care and lost revenue for hospitals.
Navigating the complexities of each of these programs and understanding the nuances of eligibility criteria require specialized skills and dedicated attention that are not always available within the walls of a hospital. Or, if they are, a disproportionate amount of time and resources are spent on them.
Most eligibility efforts center around Medicaid, but that’s not the only program hospital revenue cycle departments should have on their radar. Here are three other reimbursement programs that patients may be eligible for:
The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 allows some employees and their beneficiaries to continue health insurance coverage for specified periods of time (usually 18 months) after the loss of employment or other qualifying events, such as a reduction in work hours, divorce or aging out as a dependent. In order to continue coverage, individuals have to pay a premium. Individuals also have to purchase the COBRA coverage within 60 days of losing employer-sponsored coverage.
COBRA is not universally available to all employees—the federal law mandates it for private-sector companies with at least 20 employees—but states may have their own COBRA-like programs for smaller companies.
Social Security Disability
Two types of disability benefits are available under the Social Security program—Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). While they both provide financial assistance to disabled individuals and in some cases their beneficiaries, medical coverage can also be available to applicants.
SSDI recipients can be covered under Medicaid and after a 24-month waiting period they can also receive Medicare coverage. SSI recipients, on the other hand, are usually eligible for state Medicaid coverage, which has no waiting period. Some states automatically enroll SSI recipients in the Medicaid program, while others require a separate application.
Third-Party Liability Insurance
On average, only about 3 percent of a hospital’s accounts receivable comes from workers’ compensation, auto accident insurance and general liability claims, but these are among the most complicated receivables.
If a patient is admitted to the hospital due to an auto accident or work-related injury, tracking down the responsible party and the existence of liability insurance is a complicated part of the process.
In the case of an auto accident, the primary payer is typically the auto insurance company of the at-fault driver or, in no-fault states, the policy of the injured driver. In some states where it’s required, optional med-pay insurance or Personal Injury Protection (PIP) insurance may also be responsible. Once certain limits are reached, then a secondary insurance, often the patient’s health insurance, takes over.
When it comes to on-the-job injuries, the workers’ compensation insurance policy held by the employer is often the responsible party.
In addition to improved Medicaid outcomes, Parallon’s specialized staff is trained to find all alternate sources of reimbursements—such as COBRA, Social Security disability and state-specific reimbursement programs. Just as with Medicaid Eligibility, Parallon is vigilant about a customer-focused approach to determining eligibility for these other programs, and it devotes training to ensure highly satisfactory customer experiences.