Amidst rising inflation, workforce shortages and sharp fluctuations in the demand for high-margin elective procedures, today’s healthcare organizations are facing financial pressures that are nearly unprecedented in scope. 2022 was the most financially difficult year for hospitals, health systems and physician practices since the beginning of the COVID-19 pandemic, with data from the American Hospital Association showing that more than two-thirds of hospitals will report operating losses for 2022. Hospitals’ total operating expenses increased by $135 billion over the past year and a record-breaking number of rural hospitals shut down service lines or closed entirely.
The extent of these challenges is so great that it threatens access to care and services for many populations. With the U.S. unemployment rate still elevated above pre-pandemic levels and currently trending upwards, under- and uninsured patients – and those experiencing coverage gaps – are now seeking care in large numbers. And these numbers are expected to climb further when temporary pandemic emergency measures expire. According to the Commonwealth Fund, more than two-fifths of working-age American adults (43%) are currently under- or uninsured or have been without coverage within the past year.
Given this reality, it’s incumbent upon provider organizations to investigate all possible sources of coverage or additional funding for their patients, including state Medicaid agencies, Social Security Disability Insurance (SSDI), Workers’ Compensation, Third Party Liability (TPL) and special financial assistance for crime victims. However, navigating the complex landscape of state and federal programs – and understanding their registration processes – can be daunting for short-staffed provider organizations.
Leveraging the right third-party resources – those that can bring both the necessary human expertise and the right technology platform to bear on the problem – is essential. Such resources can make it possible for healthcare organizations to provide much-needed coverage and additional options for large volumes of patients, expanding access to care while decreasing provider organizations’ account receivables.
The complexities of determining eligibility for state and federal funding
Ensuring affordable access to healthcare has long been challenging for a significant percentage of the U.S. population, but today’s inflationary pressures are exacerbating the problem. “Consumers see rising prices for gasoline and groceries, for staples like bread and milk and eggs,” says Tammy Bliss, U.S. Senior Service Delivery Leader for Revenue Cycle Management at Cognizant Healthcare Solutions. “By no means are healthcare organizations exempt from these pressures. They’re facing higher costs for supplies, drugs and equipment, while worker shortages are driving salaries upwards. At the same time, in the aftermath of the pandemic, their self-pay portfolios are growing.”
Proactively determining eligibility for coverage is important for protecting revenues, but it can also be a complex and labor-intensive process. Many patients, including members of vulnerable populations, remain unaware of safety net programs that are available to them. Medicaid eligibility and benefits can vary from state to state, as can eligibility for personal injury protection (PIP) and liability coverage. Understanding the rules and regulations governing eligibility for SSDI can also be daunting and the application process is lengthy, especially if multi-step appeals are involved.
However, staffing shortages are widespread across the healthcare industry and they’re not just impacting clinical roles. Provider organizations are also struggling to fill administrative positions and it’s especially difficult to recruit and hire candidates who thoroughly understand state and federal guidelines surrounding eligibility. With additional administrative support, provider organizations can help underinsured patients find additional coverage, converting the under- and uninsured into insured patients and reducing patient bad debt and self-pay volumes across the board.
“Bringing in a partner gives you access to the right expertise upfront, so that you can immediately screen patients to determine eligibility for coverage from all possible payor sources,” says Bliss. “The real advantage lies in having access to that knowledge of the rules and regulations — not to mention legal acumen – as soon as you begin registering a patient.”
The right blend of human expertise and technical capabilities
To maximize revenues from underinsured patients by ensuring that all possible funding sources have been considered, provider organizations often need additional administrative support. This can be a game-changer when in-house staff are too busy to identify and secure coverage for every patient, manage the long turnaround times that application processes involve and keep themselves informed about eligibility rules and ever-changing regulations.
Besides this all-important human expertise, administrative teams also benefit from having access to the right tools and technologies. A proprietary platform that includes a rules-based engine to match patients with programs they’re eligible for can increase enrollment and an algorithm-based outreach process can deliver industry-leading member contact rates. The secret to success is ensuring that teams are inputting the right data into an intelligent technology ecosystem. But it’s just as important to have the right processes and workflows in place, especially for communicating with eligible members.
“Having the right technology is important, but human expertise is even more important,” Bliss explains. “You need to lead with the industry knowledge and then the technology is built upon that foundation.”
When provider organizations find the right third-party partner to help them build out these capabilities, the result is a win-win for everyone involved: providers, payers, patients and their communities. Provider organizations can help patients break the cycle of dependency on free care, while also improving revenues and protecting their bottom line. With less bad debt and better cash flow, they’ll have more resources to reinvest in their communities. Ultimately, this will improve patient satisfaction rates by decreasing out-of-pocket expenses and providing better access to care.
Discover how Cognizant’s comprehensive Revenue Cycle Management Services are helping healthcare organizations lessen the financial burden on their patients while decreasing account receivables. Visit our website to learn more.