Why outsource? Enhance the revenue cycle with third-party eligibility and enrollment specialists
Current economic conditions and the changing healthcare landscape present a host of challenges to both patients and healthcare providers. An increasing portion of the population is without medical insurance and is unaware that they may qualify for government assistance programs such as Medicaid, Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). Additionally, enrolling in these programs, particularly disability programs, has proven to be a daunting task for individuals, with qualification rules that are difficult to understand and a seemingly never-ending stack of paperwork to fill out. And, when patients are unable to secure coverage, hospitals feel the pain with a high number of uninsured filling beds.
Many hospitals attempt to mitigate the problems individuals have with securing government coverage by screening self-pay patients for eligibility for state/federal programs and assisting with enrollment. This helps, but it is often not enough. The process requires not only a high level of expertise and time to devote to an arduous follow-up process, but it can also become a drain on in-house staff, as those employees typically assigned to eligibility and enrollment are needed in other areas of the hospital. And, many organizations simply lack the resources to keep personnel properly trained to perform this function.
As hospitals continue to struggle with declining reimbursement rates and an increasing self-pay population, many have begun outsourcing their eligibility and enrollment programs. Under this model, specialists who act as patient advocates are called in to perform the tasks of screening the uninsured for eligibility and helping patients complete the enrollment process while at the hospital. Outsourcing this important service has several advantages:
• Eligibility specialists are experts in their field and hospitals are not responsible for ongoing training. No additional time or resources are required on the healthcare organization’s part to ensure that patients are being provided with the best possible opportunity to obtain coverage.
• Hospital staff can focus on other core areas. No longer must an employee who may not be familiar with the various programs and processes be responsible for an overwhelming list of self-pay patients, in addition to his or her normal daily responsibilities.
• In many cases, the payment model for eligibility and enrollment outsourcing firms is contingency-based. This means the hospital incurs no up-front costs. As it is the job of the eligibility specialist to obtain coverage for the uninsured, no payment is made to the third-party organization until the hospital gets paid.
To make this process as smooth as possible, a reputable eligibility and enrollment firm will ensure specialists become fully integrated with the hospital staff. This approach is key to workflow and patient satisfaction—individuals are often not aware that the person assisting with their insurance coverage is actually not an employee of the hospital. When an uninsured person is admitted, specialists are able to meet with him or her as soon as possible to assess what forms of coverage may be available. Once it is determined that a patient is eligible for a program, the specialist assists the patient with the enrollment process, ensuring that all components of the application are completed and all necessary information is submitted.
While hospitals may be able to get by with in-house eligibility and enrollment services, the benefits of outsourcing are clear. With dedicated specialists on-site, working on behalf of both the patient and the provider, the revenue cycle gets a welcome lift while in-house staff is able to focus on other areas. Patients are assisted with the application process and receive much needed medical coverage that follows them outside of the hospital—allowing them to take control of their own health futures.
Ulrich Brechbühl is CEO of Chamberlin Edmonds, an Emdeon company. Atlanta-based Chamberlin Edmonds serves as a patient advocate providing custom-tailored eligibility services to hospitals nationwide.
