Community Benefit:
Raising the Bar through People,
Partnerships and Technology
UPMC Patient Financial Services Center
April Langford
MedAssets
Julie Kay
Overview
• Objectives
• Community Benefit: The industry status
• About UPMC
•
•
•
•
•
•
•
Environmental conditions
Identifying the need
Key indications
Executing Action
Process, Technology and Partnerships
Current outcomes
Lessons Learned
• Final thoughts
2
Objectives
• Understand how UPMC confronted their Community
Benefit initiatives
• Identify innovative and creative ways for performing
community-focused initiatives
• Learn how technology and improved processes can
impact community outreach.
3
Community Benefit: Industry Status
• Patient Protection and Affordable Care Act (PPACA)
• Community Health Needs Assessment
• Financial Assistance Policy
• Tax Exempt Status Threatened
• Patient Financial Management
•
•
•
•
4
Social Service vs. Collection Effort
Detailing Program Practices
Identifying Outcomes
Sharing the impact with the Community
About UPMC
•
Integrated global healthcare enterprise headquartered in Pittsburgh
•
One of the largest non-profit health systems in the nation
• Hospital and Community Services – 20 tertiary , community and specialty
(Psychiatric, Women’s Children’s) hospitals, 400 outpatient sites
• Physician – nearly 5,000 physicians with privileges at UPMC hospitals,
including more than 3,000 employed
• Insurance – UPMC Health Plan has over 1.6 million members and covers
commercial, Medicare Medicaid, CHIP, behavioral health, employee
assistance and workers’ compensation segments
• International and Commercial Services – exporting knowledge and expertise
internationally with footprints in Italy, Ireland, China, and Japan
•
Transformed the economic landscape in Western Pennsylvania
• 54,000 employees; largest employer in Pittsburgh
• The UPMC Corporate Revenue Cycle (CRC) manages
all facilities in an integrated model
FY11 Results:
•
•
•
•
•
•
•
•
•
•
•
Net Patient Service Revenue
Annual Cash Collections
Annual Claims Processed
Clean Claims
Average Days in AR
% A/R >90 Days
Denials
Denial Direct Write-Offs
Uncompensated Care to Gross Revenue
FTEs
Average Revenue per FTE
$4.1B
$4.1B
4.2M
92.5%
34
5.7%
0.8%
0.1%
2.63%
378
$10.87M
UPMC Patient Financial Services Center
The UPMC Patient Financial Services Center was designed to assist
uninsured and underinsured individuals and families in finding financial
solutions for medically necessary services.
We developed our Patient Financial Services Center such that
caregivers and patients can access financial services and counseling
throughout the entire continuum of care.
7
UPMC Patient Financial Services Center:
Identification of Need
National Indicators*:
•
Beginning in 2014, the American Recovery and Reinvestment Act will extend MA
eligibility to all Americans under age 65 whose family income is at or below 133% of
federal poverty guidelines.
PA State Indicators**:
•
Pennsylvania’s uninsured population showed an increase in the past year from 9.7% to
11% of the overall population.
UPMC Specific Indicators:
•
•
•
Increasing Self Pay Population and Patient Balances
Increasing Uncompensated Care
Uninsured/underinsured individuals may not be aware of programs designed to provide
financial assistance.
*http://www.ncsl.org/issues-research/health/medicaid-home-page.aspx
**2011 America's Health Rankings® by the United Health Foundation
8
UPMC Patient Financial Services Center:
Identification of Need – PA State Indicators
12%
Uninsured Population of Pennsylvania
11%
10%
9%
8%
7%
6%
9
Data taken from 1990-2011 America's Health Rankings® by the United Health
Foundation.
UPMC Patient Financial Services Center:
Identification of Need – UPMC Specific Indicators
Total Number of Patient Balances
80,000
74,375
71,867
70,000
60,606
60,000
39%
Increase
since
FY09
51,888
50,000
40,000
30,000
20,000
FY09
10
FY10
FY11
FY12 TD (Dec)
UPMC Patient Financial Services Center:
Identification of Need – UPMC Specific Indicators
Average Patient Balance
$620
$607
$600
$590
18%
Increase
since FY09
$580
$560
$540
$520
$515
$517
FY09
FY10
$500
$480
$460
11
FY11
FY12 TD
UPMC Patient Financial Services Center:
Identification of Need – UPMC Specific Indicators
Uncompensated Care Trending
$50,000,000
$45,000,000
$40,000,000
$35,000,000
$30,000,000
$25,000,000
$20,000,000
$15,000,000
$10,000,000
12.68%
12.37%
12.11%
11.39%
14%
12%
10.90%
10%
8%
6%
2.77%
2.66%
2.45%
2.59%
2.54%
4%
2%
2.64%
0%
FY11 Q1
Avg
FY11 Q2
Avg
FY11 Q3
Avg
Total Uncompensated Care Write-Offs
12
12.53%
FY11 Q4
Avg
Percentage (Gross)
FY12 Q1
Avg
FY12 Q2
Avg
Percentage (Net)
UPMC Patient Financial Services Center:
Positive Outcomes
13
•
Patient qualifies for Medical Assistance
•
Patient qualifies for UPMC Financial Assistance
•
Patient obtains other funding from programs such as:
•
Victims of Violent Crimes
•
Leukemia & Lymphoma society
•
National Breast and Cervical Cancer Early Detection Program
•
Cash collection increases as patients qualify for external funding
•
Cash collection increases as patients make payments
•
Affordable and manageable payment plans are set up
•
Individual’s credit rating is protected from bad debt collection efforts
UPMC Patient Financial Services Center:
Negative Outcome
Patient sent to Bad Debt
due to inability to pay
14
UPMC Patient Financial Services Center
Referrals to the UPMC PFSC occur along the entire continuum of care, and a proactive approach
is taken to ensure that all uninsured/underinsured patients are identified as soon as possible
Primary Initiatives
Points of Referral
Obtain MA for Patient
Pre Arrival
Point of Service
Post Service
.
UPMC
PFSC
Provide Financial Assistance for
Qualified Patients
Create Effective Collection
Process
After the patient is referred to the UPMC PFSC, a specialist will work with the patient to determine if they qualify
for Medical Assistance, Financial Assistance or have the ability to pay. They will then work with the patient to
assist in the application process and/or set up a mutually agreeable payment plan.
15
Proactive Identification of Uninsured/Underinsured Patients
and Patient Responsibility - Workflow
•Early identification of individuals with financial need enables us to properly refer patients to the
appropriate financial services program.
•Uninsured/Underinsured patients are identified in our pre-arrival center via our ePayer Insurance
Verification and Self-Pay worklists. Onsite Case Managers or Social Workers identify
uninsured/underinsured patients presenting to sites and call or email the UPMC PFSC to notify
specialists of the patient’s financial situation.
•If patients are unable to pay, co-payments, coinsurance and any other outstanding patient balances at
the point of service, referrals to the PFSC are initiated. UPMC PFSC specialists reach out to the
patient and work with them to pursue program/payment options.
•The goal is to reduce “Elective” Bad Debt and to minimize financial risk to UPMC and the patient.
16
Proactive Identification of Uninsured/Underinsured
Patients and Patient Responsibility - Technology
•The UPMC eEligibility electronic Insurance Verification system identifies patient responsibility pre-arrival and automatically
posts patient responsibility into the patient accounting system for collection at point of service.
•Our UPMC Self-Pay electronic worklist identifies uninsured/underinsured patients prior to service . We can then reach out to
patients and initiate steps to secure payment and/or initiate financial counseling.
•Criteria for qualification to the UPMC PFSC Self-Pay Electronic Worklist:
•
•
•
17
All Uninsured patients are automatically added to the worklist
All Auto patients are automatically added to the worklist
Underinsured patients are referred from the pre-arrival insurance verification worklist via a transfer button
•
Workers’ Compensation with no Secondary Insurance
•
Medicare Part A Inpatients with no Secondary Insurance
Proactive Identification of Uninsured/Underinsured
Patients and Patient Responsibility - Outcomes
Pre Arrival Uninsured/Underinsured SDS and Outpatient Radiology - Combined
18
•
Insurance Coverage Identified
59%
•
Referred to UPMC PFSC
– MA Eligibility Approved / Pending
– Financial Assistance Approved / Pending
– On-Going Internal Collection Process
– Payment Collected
41%
55%
24%
18%
3%
Proactive Identification of Uninsured/Underinsured Patients
and Patient Responsibility - Outcomes
37% Decrease
since Nov 10
Non-Emergent Uncompensated Care as a Percentage of Total Uncompensated Care
13.0%
11.9%
12.0%
11.0%
10.0%
11.2%
10.8%
11.2%
10.7%
10.5%
10.1%
9.2%
9.5%
9.6%
9.8%
9.0%
9.0%
8.0%
7.9%
7.2%
7.6%
7.50%
6.50%
7.0%
6.0%
5.0%
4.0%
19
5.70%
Proactive Identification of Uninsured/Underinsured Patients
and Patient Responsibility - Outcomes
•
219% Increase
since Feb 2010
$450,000
Average Monthly Point of Service Collections
•
$300,000
•
$150,000
•
$0
Collections w/in 8 Days of Service
20
ePayer automatically gets
Patient Responsibility
information from Payer
Portals and posts it into
the patient accounting
(PA) system for POS
collections
Collection efforts are
tailored based upon
Propensity to Pay
Segmentation posted in
PA System
Scripting is provided to
Registrars for various
scenarios
Patients who cannot pay
are referred to the UPMC
PFSC via phone, email,
fax, and documentation in
the PA system.
Medical Assistance Eligibility - Workflow
•Determining a patient’s eligibility for alternative coverage sources is a
major piece of the UPMC PFSC workflow.
•We start the process with evaluating the patient’s eligibility for their state
Medical Assistance Program. Most states have a 90 day retroactive
eligibility period so it is crucial to identify potentially eligible patients
quickly.
• We use 5 selected vendors to assist Inpatients during the Medical
Assistance application process
• We created an internal Medical Assistance Eligibility team to assist
Outpatients during the Medical Assistance application process.
21
Medical Assistance Eligibility - Workflow
•
Uninsured patients are provided with a specialist to facilitate the Medical Assistance application process.
•
Specialists complete and submit the Medical Assistance application on behalf of patient and act as a
liaison with the Medical Assistance office to attempt to gain eligibility for the patient.
•
The process ensures that applications are submitted quickly and completely.
•
Specialists assist patients throughout the entire application process. They follow up with the Medical
Assistance office and the patient to verify that all documentation is submitted.
UPMC’s Medical Assistance eligibility work tool (eMA) monitors this process, both
internally and externally, ensuring that applications are processed in a timely fashion and
that thorough follow-up is completed.
22
Medical Assistance Eligibility - Technology
eMA – Medical Assistance Eligibility Worktool
•
eMA actively identifies uninsured/underinsured patients and ensures appropriate follow up during the
MA eligibility process.
•
eMA also identifies individuals who have been eligible for medical assistance within the past two years,
pregnant women, and children with chronic illnesses and automatically adds them to the worklist for
contact and financial counseling.
•
eMA enables Medical Assistance specialists to contact patients prior to or quickly after their service, to
increase the likelihood of eligibility.
•
eMA highlights the status of the account in the eligibility process, enabling Medical Assistance
specialists to easily track individual accounts and initiate data driven process improvement efforts to
expedite eligibility.
23
Medical Assistance Eligibility - Technology
eMA – Medical Assistance Eligibility Worktool
24
Medical Assistance Eligibility - Technology
eMA – Medical Assistance Eligibility Worktool
25
Medical Assistance Eligibility - Outcomes
Vendor Referrals to MA – Inpatient/Outpatient
3000
2800
2600
2400
2200
2000
1800
1600
1400
1200
1000
26
2660
2407
1930
1820
1649
2534
2539
2616
2454
2449
Medical Assistance Eligibility - Outcomes
800
700
600
500
400
300
200
100
0
704
Internal Referrals to MA - Outpatient
730
387
Started Internal
MA Process
279
Changed Referral Criteria
to EXCLUDE Balances
<$1000
Oct-11
Nov-11
Referrals to MA
27
Dec-11
Jan-12
Medical Assistance Eligibility - Outcomes
Results of MA Eligibility
Process
7,303 patients, or 64%,
were approved for MA
In FY11, we referred 11,522
Patients* to MA
Of those 11,440 closed
applications for patients
referred to MA…
$50,507,572 in MA cash
was received
7.28% Cash**
2,144 patients, or 52%
were denied as Over
Income
85.72% FA W/Os
7.00% BD W/Os
4,137 patients, or 36%,
were denied MA. Of
those denied MA…
28
*Includes IP and OP Referrals
**Includes Patient, Insurance, and Out for
Collection Payments
9.02% Cash**
1,993 patients, or
48% were denied
as Uncooperative
83.86% FA W/Os
7.12% BD W/Os
UPMC Financial Assistance Eligibility - Workflow
•As soon as we determine if an uninsured/underinsured patient is not
eligible for Medical Assistance, we evaluate the patient for the UPMC
Financial Assistance program.
•UPMC PFSC Specialists work with the patients to complete the
application and collect all required documentation necessary to make a
determination for financial assistance.
•By helping the patients navigate this process, we are able to ensure that
all qualifying patients are able to get necessary financial help.
29
UPMC Financial Assistance Eligibility - Workflow
Patients may be eligible for UPMC Financial Assistance for medically necessary services if they:
•
Have limited or no health insurance
•
Can demonstrate financial need
•
Provide UPMC with necessary information about household finances
Financial assistance is not available for:
•
Insurance co-pays (excluded unless the co-pay balance is a hardship)
Financial assistance is typically not available for:
•
Deductibles
•
When a person fails to comply reasonably with insurance requirements (such as obtaining authorizations and/or
referrals)
•
For persons who opt out of available insurance coverage
•
International patients
30
UPMC Financial Assistance Eligibility - Workflow
2011 Financial Assistance Eligibility Income Guidelines
31
Family Size
Income equal to <= 200% the of Federal
Poverty Level* equates to 100%
Financial Assistance Balance
Forgiveness for the Patient
1
2
3
4
5
6
7
8
$21,780
$29,420
$37,060
$44,700
$52,340
$59,980
$67,620
$75,260
Income equal to 201% to 400% of Federal
Poverty Level* equates to 85% Financial
Assistance Balance Forgiveness for the
Patient
$43,560
$58,840
$74,120
$89,400
$104,680
$119,960
$135,240
$150,520
UPMC Financial Assistance Eligibility - Outcomes
Applications Received for Financial Assistance
3,500
3,000
2,500
3013
3229
2,000
32
Over 200 More Applications Received per Month in FY 12
than FY11
UPMC Financial Assistance Eligibility - Technology
eFA – Financial Assistance Eligibility Worktool
33
UPMC Financial Assistance Eligibility - Technology
eFA – Financial Assistance Eligibility Worktool
34
UPMC Financial Assistance Eligibility - Outcomes
Financial Assistance Write Offs
$45,000,000
$40,545,828
$40,000,000
$35,000,000
$30,707,207
$30,000,000
$25,956,409
$25,000,000
$20,000,000
35
$30,308,644
$29,989,496
$32,700,312
Identification of Patient Ability to Pay – Workflow
Self-Pay Segmentation
•When the patient enters our Self-Pay automated predicative dialer system for
collections, they are immediately segmented into one of 6 segments, directing
the workflow of the collection process.
•We strive to prevent patients who have the ability to pay from being referred to
bad debt at all costs. We work with patients to explore every avenue to obtain
payment from alternative coverage sources and set up affordable payment
plans.
36
Identification of Patient Ability to Pay – Workflow
Self-Pay Segmentation
• Segment 1: High Propensity – Previous Payment at UPMC or
Collection Agency
• Segment 2: Medium Propensity – New Patient or Patient on Payment
Plan
• Segment 3: Low Propensity – No Payment History at UPMC or
Collection Agency
• Segment 4: All Balances < $100
• Segment 5: Financial Assistance – Approved w/o Application
• Segment 6: Financial Assistance – Approved w/ Application or
Currently Applying
37
Identification of Patient Ability to Pay – Outcomes
Self-Pay Segmentation
Internal Score - Based Upon Payment History
Vendor
Score
10
20
30
40
Balance
<$100
No Score
Total
A-FA
B-Account in F-Applied
Approved
Bad Debt
for FA
53
1,437
68
15
804
39
33
1,976
83
74
3,198
157
<$100
I-Active
Installment
Plan
30
10
29
50
P-Previously
N-New
made
Patient
payment
No Score Grand Total
2
229
88
1,907
155
23
1,046
1
239
68
2,429
3
723
87
4,292
160
279
19,716
18,295
47,685
19,716
19,716
256
431
1,708
9,123
545
892
1,164
1,170
5,662
7,008
8,800
9,066
15.57% of referrals to UPMC PFSC are identified through scoring
38
UPMC Financial Assistance Eligibility - Outcomes
Total Patient Cash by Month
Segmentatio
$8,500,000
$8,000,000
$7,927,119
$7,559,460
$7,552,959
$7,500,000
$7,000,000
$6,500,000
$6,000,000
$7,501,545
$7,192,113
$5,972,330
$6,478,221
$6,323,577
$5,674,124
$5,500,000
$5,000,000
$4,911,080
$4,500,000
FY11 Q1 AvgFY11 Q2 AvgFY11 Q3 AvgFY11 Q4 Avg
39
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
UPMC Financial Assistance Eligibility - Outcomes
$45,000,000
UPMC PFSC Outcomes
$40,545,828
$40,000,000
$35,000,000
$32,700,312
$30,707,207
$30,000,000
$30,308,644
$29,989,496
$25,956,409
Charity Care
Writeoffs
Bad Debt Writeoffs
$25,000,000
$20,000,000
Patient Cash
Collected
$14,744,343
$15,000,000
$8,962,483
$11,535,961
$10,000,000
$5,000,000
$5,337,037
$5,660,943
$11,051,380
$8,793,503
$6,818,939
$8,140,674
$8,763,775
$9,343,918
$3,519,099
$0
FY11 Q1 Avg
40
FY11 Q2 Avg
FY11 Q3 Avg
FY11 Q4 Avg
FY12 Q1 Avg
FY12 Q2 Avg
UPMC Financial Assistance Eligibility - Outcomes
Financial Assistance and Bad Debt as a Portion of
Uncompensated Care
80%
73%
73%
70%
60%
50%
52%
48%
54%
46%
55%
45%
40%
27%
30%
27%
20%
10%
0%
41
FY08
FY09
FY10
FY11
FY12 TD
Bad Debt
Financial Assistance
UPMC Patient Financial Services Center:
Self-Pay - Outcomes
UPMC PSFC Opportunity – Bad
Debt
FY12 TOTAL YTD Bad Debt Adjustments
(Annualized)
FY11 TOTAL Bad Debt Adjustments
Row Labels
IP Emergent
IP Non-Emergent
OP Emergent
OP NonEmergent
Total
42
Grand Total
Row Labels
%
$24,417,320
19%
$5,790,143
4%
$69,950,615
53%
24%
$31,950,788
$132,108,866
IP Emergent
Grand Total
%
$12,368,515
13%
$3,448,170
4%
OP Emergent
$55,180,196
58%
OP NonEmergent
$23,919,970
25%
Total
$94,916,851
IP Non-Emergent
UPMC Patient Financial Services Center:
Essential Partnerships
The presented outcomes would be impossible to achieve without
effective and mutually beneficial partnerships with the following:
•
•
•
•
•
•
Patient Access – Insurance Verifiers
On-Site Staff – Registrars, Case Managers, Social Workers
UPMC PFSC Specialists
Vendors
County/State MA Office
CFOs and other Operational Leaders
And most of all,
• Our Patients
43
Overall Results
Key Indicator
Average Monthly Point of
Service Cash Collections
Average Monthly Referrals to
MA
Average Monthly Referrals to FA
Average Monthly Write Offs to
FA
Average Monthly Write Offs to
BD
Financial Assistance as a % of
Uncompensated Care
Bad Debt Write Offs as a % of
Uncompensated Care
Average Montly Patient Cash
Collections
44
FY11
FY12 TD
Improvement
$266,042
$375,068
41%
2,545
3,058
20%
3,012
3,229
7%
$29,240,439
$36,623,070
20%
$11,009,073
$7,285,240
-51%
73%
73%
0%
27%
27%
0%
$8,008,117
$8,950,074
11%
Final Thoughts
45