Social Security Disability Eligibility Success Requires Specialized Expertise and a Process Built for the Long Haul

Social Security Disability Eligibility Success Requires Specialized Expertise and a Process Built for the Long Haul

Hospitals dealing with large self-pay A/R balances often look to improve their eligibility efforts and enroll patients in reimbursement programs that cover their care. Within the eligibility realm, no program proves to be more challenging to providers and eligibility vendors than Social Security Disability (SSD).

Even experienced in-house eligibility teams are often intimidated by the complexity of SSD’s eligibility requirements, which can require more than a year’s worth of specific training to understand well. Beyond the complexity of understanding eligibility, seeing an SSD account through application to reimbursement can take two years or more, and it requires a process built to foster success.

For many vendors, SSD is not a strength of their offering either. But not executing SSD eligibility well is a little bit like McDonald’s not selling french fries. It’s core to vulnerable patients receiving access to care and hospitals being compensated for care delivered.

Here’s what providers should consider when reviewing the adequacy of their SSD eligibility efforts, and whether your internal team or your current vendor is adequately meeting your needs. 

The Complexity of SSD

Your staff or outside vendors have a much easier time determining eligibility in Medicaid than in SSD (which will eventually convert to Medicaid benefits) because you would typically evaluate two factors:

1) Does the patient meet income requirements?


2) Does the patient meet family demographic considerations, such as having children or expecting a baby?

SSD eligibility requires more information to determine whether a patient has a qualifying disability. Eligibility depends on myriad clinical eligibility factors (Is the patient an amputee? Is the amputation below or above the knee?), in addition to income and family demographic considerations.

The cases can be very lengthy and time consuming to resolve as well. When you start to dedicate an experienced team to potential SSD accounts, you may be looking at one to three years to convert that account and generate dollars. Where staff turnover is an issue, it’s important that someone, whether in an eligibility department or working for a vendor, is monitoring that account across a longer period of time.

What Does Success Look Like?

Success starts from an experienced staff person trained in reviewing and researching a patient’s medical condition and able to work compassionately with patients they are trying to enroll in SSD. In some cases, the patient doesn’t view themselves as being disabled, and it takes a delicate touch for an eligibility vendor to be helpful in that instance. The high skill level to determine eligibility is fostered through continuous training.

Successful SSD eligibility staffing requires a team supporting the individuals who are working with patients and helping on the more complicated accounts, and finding ways to help them convert. One of the capabilities that can aid the team is strong government relations personnel to help teams be aware of changes in regulation.

Because the accounts can linger without resolution, the staff must have a process in place to ensure that cases don’t fall through the cracks. Monitoring performance, by using technology to track progress metrics, can help ensure that the team is helping the hospital yield more conversions for eligible SSD patients.

Other Considerations

For states that did not adopt Medicaid expansion, it’s more critical for SSD eligibility to be executed well. In expansion states, it may be the path of least resistance to enroll a patient directly in Medicaid, and being successful with SSD may be less consequential to the bottom line. If you are in a non-expansion state, you need to evaluate whether your SSD efforts are adequate. Large self-pay A/R balances is one signal that you might need help.

Another reason to ensure optimal SSD eligibility is that hospitals and health systems that provide care to vulnerable populations are eligible for Disproportionate Share Hospital (DSH) payments. (More than 15 percent of a hospital’s patients meet a DSH qualification.) Keeping track of SSD payments, and how that will help DSH payments, is part of what a provider should expect from their internal team or vendor.

If you’d like to understand more about how Parallon can help you address the complex challenges posed by SSD eligibility, contact our eligibility and advocate experts.