Community Benefit: Raising the Bar through People, Partnerships and Technology

Community Benefit: Raising the Bar through People, Partnerships and Technology

UPMC Patient Financial Services CenterApril LangfordMedAssetsJulie 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

• Social Service vs. Collection Effort• Detailing Program Practices• Identifying Outcomes• Sharing the impact with the Community

4

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 $4.1B• Annual Cash Collections $4.1B• Annual Claims Processed 4.2M• Clean Claims 92.5%• Average Days in AR 34• % A/R >90 Days 5.7%• Denials 0.8%• Denial Direct Write-Offs 0.1%• Uncompensated Care to Gross Revenue 2.63%• FTEs 378• Average Revenue per FTE $10.87M

UPMC Patient Financial Services Center

7

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.

UPMC Patient Financial Services Center:Identification of Need

8

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

Uninsured Population of Pennsylvania

9

19901992

19941996

19982000

20022004

20062008

20106%

7%

8%

9%

10%

11%

12%

Data taken from 1990-2011 America's Health Rankings® by the United Health Foundation.

UPMC Patient Financial Services Center:Identification of Need – PA State Indicators

UPMC Patient Financial Services Center:Identification of Need – UPMC Specific Indicators

10FY09 FY10 FY11 FY12 TD (Dec)

20,000

30,000

40,000

50,000

60,000

70,000

80,000

51,888

60,606

74,375 71,867

Total Number of Patient Balances

39% Increase

since FY09


11

FY09 FY10 FY11 FY12 TD$460

$480

$500

$520

$540

$560

$580

$600

$620

$515 $517

$590$607

Average Patient Balance

18% Increase

since FY09


12

FY11 Q1 Avg

FY11 Q2 Avg

FY11 Q3 Avg

FY11 Q4 Avg

FY12 Q1 Avg

FY12 Q2 Avg

$10,000,000$15,000,000$20,000,000$25,000,000$30,000,000$35,000,000$40,000,000$45,000,000$50,000,000

0%

2%

4%

6%

8%

10%

12%

14%

2.77%

2.64%

2.66% 2.45% 2.59% 2.54%

12.68% 12.11%11.39% 10.90%

12.37% 12.53%

Uncompensated Care Trending

Total Uncompensated Care Write-Offs Percentage (Gross) 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

14

Patient sent to Bad Debt due to inability to pay

UPMC Patient Financial Services Center

15

Points of Referral

Obtain MA for Patient

Provide Financial Assistance for Qualified Patients

Pre Arrival

Post Service

Point of ServiceUPMCPFSC

Primary Initiatives

Create Effective Collection Process

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.

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.

16

•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.

Proactive Identification of Uninsured/Underinsured Patients and Patient Responsibility - Workflow

Proactive Identification of Uninsured/Underinsured Patients and Patient Responsibility - Technology

17

• 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:

• 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

18

• Insurance Coverage Identified 59%

• Referred to UPMC PFSC 41%– MA Eligibility Approved / Pending 55%– Financial Assistance Approved / Pending 24%– On-Going Internal Collection Process 18%– Payment Collected 3%

Pre Arrival Uninsured/Underinsured SDS and Outpatient Radiology - Combined

19

Non-Emergent Uncompensated Care as a Percentage of Total Uncompensated Care

Jul-10 Aug-10

Sep-10 Oct-10 Nov-10

Dec-10

Jan-11 Feb-11 Mar-11

Apr-11 May-11

Jun-11 Jul-11 Aug-11

Sep-11 Oct-11 Nov-11

Dec-11

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

11.0%

12.0%

13.0%

11.2%10.8%

11.2%10.5%

11.9%

9.2%9.5% 9.6%

10.7%10.1%

9.8%

9.0%

7.2%

7.9%7.6%

5.7%

6.5%

7.5%

37% Decrease since Nov 10


20

FY10 Q3FY10 Q4

FY11 Q1FY11 Q2

FY11 Q3FY11 Q4

FY12 Q1FY12 Q2

$0

$150,000

$300,000

$450,000 Average Monthly Point of Service Collections

Collections w/in 8 Days of Service

219% Increase since Feb 2010


• 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.

21

• 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.

• 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.

Medical Assistance Eligibility - Workflow

22

• 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.

Medical Assistance Eligibility - Workflow

Medical Assistance Eligibility - Technology

23

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.

Medical Assistance Eligibility - Technology

24

eMA – Medical Assistance Eligibility Worktool

25

Medical Assistance Eligibility - TechnologyeMA – Medical Assistance Eligibility Worktool

Medical Assistance Eligibility - Outcomes

26

FY10 Q1

FY10 Q2

FY10 Q3

FY10 Q4

FY11 Q1

FY11 Q2

FY11 Q3

FY11 Q4

FY12 Q1

FY12 Q21000120014001600180020002200240026002800

18201649

1930

2407

26602534 2539 2454

26162449

Vendor Referrals to MA – Inpatient/Outpatient


27

Oct-11 Nov-11 Dec-11 Jan-120

100200300400500600700800 704 730

279387

Internal Referrals to MA - Outpatient

Referrals to MA

Changed Referral Criteria to EXCLUDE Balances

<$1000

Started Internal MA Process

28

In FY11, we referred 11,522 Patients* to MA

Of those 11,440 closed applications for patients

referred to MA…

7,303 patients, or 64%, were approved for MA

4,137 patients, or 36%, were denied MA. Of those denied MA…

MA

APPR

OVED

MA D

ENIED

2,144 patients, or 52% were denied as Over

Income

1,993 patients, or 48% were denied as Uncooperative

Positiv

e Clos

e

Negative Close

$50,507,572 in MA cash was received

7.28% Cash**

85.72% FA W/Os

7.00% BD W/Os

83.86% FA W/Os

7.12% BD W/Os

Results of MA Eligibility Process

9.02% Cash**

*Includes IP and OP Referrals**Includes Patient, Insurance, and Out for

Collection Payments


UPMC Financial Assistance Eligibility - Workflow

29

• 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.


30

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


31

2011 Financial Assistance Eligibility Income Guidelines

Family Size

Income equal to <= 200% the of Federal Poverty Level* equates to 100%

Financial Assistance Balance Forgiveness for the Patient

Income equal to 201% to 400% of Federal Poverty Level* equates to 85% Financial Assistance Balance Forgiveness for the

Patient1 $21,780 $43,5602 $29,420 $58,8403 $37,060 $74,1204 $44,700 $89,4005 $52,340 $104,6806 $59,980 $119,9607 $67,620 $135,2408 $75,260 $150,520

UPMC Financial Assistance Eligibility - Outcomes

32

FY11

FY12 YT

D

2,000

2,500

3,000

3,500

30133229

Applications Received for Financial Assistance

Over 200 More Applications Received per Month in FY 12 than FY11

UPMC Financial Assistance Eligibility - Technology

33

eFA – Financial Assistance Eligibility Worktool

UPMC Financial Assistance Eligibility - Technology

34

eFA – Financial Assistance Eligibility Worktool


35

FY11 Q1FY11 Q2

FY11 Q3FY11 Q4

FY12 Q1FY12 Q2

$20,000,000

$25,000,000

$30,000,000

$35,000,000

$40,000,000

$45,000,000

$25,956,409

$30,707,207 $30,308,644 $29,989,496 $32,700,312

$40,545,828

Financial Assistance Write Offs

Identification of Patient Ability to Pay – WorkflowSelf-Pay Segmentation

36

•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.

Identification of Patient Ability to Pay – WorkflowSelf-Pay Segmentation

37

• 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

Identification of Patient Ability to Pay – OutcomesSelf-Pay Segmentation

38

Internal Score - Based Upon Payment History

Vendor Score <$100

A-FA Approved

B-Account in Bad Debt

F-Applied for FA

I-Active Installment

PlanN-New Patient

P-Previously made

payment No Score Grand Total10 53 1,437 68 30 2 229 88 1,90720 15 804 39 10 155 23 1,04630 33 1,976 83 29 1 239 68 2,42940 74 3,198 157 50 3 723 87 4,292Balance <$100 19,716 19,716No Score 256 1,708 545 160 1,164 5,662 8,800 18,295Total 19,716 431 9,123 892 279 1,170 7,008 9,066 47,685

15.57% of referrals to UPMC PFSC are identified through scoring


39

FY11 Q1 Avg

FY11 Q2 Avg

FY11 Q3 Avg

FY11 Q4 Avg

Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11$4,500,000

$5,000,000

$5,500,000

$6,000,000

$6,500,000

$7,000,000

$7,500,000

$8,000,000

$8,500,000

$5,972,330$5,674,124

$4,911,080

$7,927,119

$6,478,221

$7,552,959

$6,323,577

$7,559,460

$7,192,113

$7,501,545

Total Patient Cash by Month Segmenta-tion Imple-

mented


40

FY11 Q1 Avg FY11 Q2 Avg FY11 Q3 Avg FY11 Q4 Avg FY12 Q1 Avg FY12 Q2 Avg$0

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

$35,000,000

$40,000,000

$45,000,000

$25,956,409

$30,707,207 $30,308,644 $29,989,496 $32,700,312

$40,545,828

$14,744,343

$8,962,483 $11,535,961

$8,793,503 $11,051,380

$3,519,099 $5,337,037 $5,660,943 $6,818,939 $8,140,674 $8,763,775 $9,343,918

Charity Care Writeoffs

Bad Debt Writeoffs

Patient Cash Col-lected

UPMC PFSC Outcomes


41 FY08 FY09 FY10 FY11 FY12 TD0%

10%

20%

30%

40%

50%

60%

70%

80%

52%46% 45%

27% 27%

48%54% 55%

73% 73%

Financial Assistance and Bad Debt as a Portion of Uncompensated Care

Bad DebtFinancial Assistance

UPMC Patient Financial Services Center:Self-Pay - Outcomes

42

FY11 TOTAL Bad Debt Adjustments

Row Labels Grand Total %

IP Emergent $24,417,320 19%

IP Non-Emergent $5,790,143 4%

OP Emergent $69,950,615 53%

OP Non-Emergent $31,950,788 24%

Total $132,108,866

FY12 TOTAL YTD Bad Debt Adjustments (Annualized)

Row Labels Grand Total %

IP Emergent $12,368,515 13%

IP Non-Emergent $3,448,170 4%

OP Emergent $55,180,196 58%

OP Non-Emergent $23,919,970 25%

Total $94,916,851

UPMC PSFC Opportunity – Bad Debt

UPMC Patient Financial Services Center:Essential Partnerships

43

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

Overall Results

44

Key Indicator FY11 FY12 TD ImprovementAverage Monthly Point of Service Cash Collections $266,042 $375,068 41%Average Monthly Referrals to MA 2,545 3,058 20%

Average Monthly Referrals to FA 3,012 3,229 7%Average Monthly Write Offs to FA $29,240,439 $36,623,070 20%Average Monthly Write Offs to BD $11,009,073 $7,285,240 -51% Financial Assistance as a % of Uncompensated Care 73% 73% 0%Bad Debt Write Offs as a % of Uncompensated Care 27% 27% 0%Average Montly Patient Cash Collections $8,008,117 $8,950,074 11%

Final Thoughts

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Community Benefit: Raising the Bar through People, Partnerships and Technology

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