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UPMC Patient Financial Services Center

About UPMC

• UPMC is a $10 billion integrated global health enterprise

• Ranked #10 nationally, #1 in Pennsylvania, and #1 in Pittsburgh by

U.S. News and World Report

• UPMC comprises more than 20 hospitals with more than 4,500

licensed beds and 400 outpatient locations in Western

Pennsylvania

• UPMC’s insurance arm, or UPMC Health Plan, has more than 1.8

million members

• UPMC’s Annual Activity:

• 253,000+ inpatient admissions and observation cases

• 3.6 million+ outpatient visits

• 600,000+ emergency visits

• 174,000+ surgeries

• 500,000 home care visits

UPMC Patient Financial Services Center: Introduction

• 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

• National Indicators*: • Beginning in 2014, the American Recovery and Reinvestment Act

extended 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 percent to 11 percent of the overall population.

• UPMC Specific Indicators: • Increasing Self Pay Population

• Increasing Uncompensated Care

• Uninsured/underinsured individuals may not be aware of programs

designed to provide financial assistance.

Sources: *http://www.ncsl.org/issues-research/health/medicaid-home-page.aspx **2011 America's Health Rankings® by the United Health Foundation

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

Uninsured Population of Pennsylvania

Data taken from 1993-2013 America's Health Rankings® by the United Health Foundation.

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

86% Increase

since FY09


26% Increase

since FY09

Increased patient responsibility after insurance payment (i.e.,

coinsurance, deductibles) yields higher average patient balances

UPMC Patient Financial Services Center: Positive Outcomes

• 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

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.

• 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 and will work with the patient to assist

in the application process and/or set up a mutually agreeable payment plan.

UPMC Patient Financial Services Center: Identifying the Uninsured/Underinsured

• Early identification of individuals with financial need enables us to properly

financially counsel patients, reduce “Elective” Bad Debt, and minimize

financial risk to UPMC and the patient.

• Uninsured/Underinsured patients are identified in our pre-arrival center via

our eEligibility Insurance Verification worklist.

• Criteria for qualification to the UPMC PFSC Pre-Arrival Electronic Worklist:

• All Uninsured patients are automatically added

• All Auto patients with no secondary are automatically added

• Underinsured patients are referred from the Pre Arrival insurance verification

work-list 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


• If appropriate payment arrangements have not been made prior to

the date scheduled for service, in order to avoid inconvenience for

the patient and in order to ensure the efficient scheduling of

procedures, the Pre Arrival Representative will:

1. Confirm with the ordering physician that the service is Elective and

not Urgent

2. Explore appropriateness of postponing service until payment

arrangements have been established

3. Obtain a price estimate

4. Counsel the patient regarding his or her financial responsibility

5. Request payment prior to service

6. Consult the CFO if payment arrangements are not established and

the service is not postponed until financial arrangements are

established

7. Continue to work with the patient on financial situation post service

via referral to the UPMC PFSC

UPMC Patient Financial Services Center: Scheduled Uninsured – SDS and Outpatient Radiology

• Identify Insurance Coverage

• Insurance Coverage Identified 55%

• Uninsured Primary Initiatives Results

• Obtain MA For Patients

• MA Eligibility Approved / Pending 13%

• Evaluate for UPMC Financial Assistance

• Financial Assistance Approved / Pending 16%

• Effective Collection Process

• Patient Pay Amount Collected 64%

• On-Going Internal Collection Process 13%

Process Management for Scheduled Services

UPMC Patient Financial Services Center: Pre-Arrival Best Practices*

*Derived from various sources including: Interviews/discussions with Vendors, other Revenue Cycle

leaders, and resources such as the Advisory Board and HFMA

UPMC Patient Financial Services Center: Point of Service Collections

• Point of Service collections is a significant opportunity area for most

hospitals.

• As the healthcare climate continues to shift, we have seen an

increase in uninsured/underinsured patients and increases in

insured patients with high –deductible health plans (HDHPs).

Maximizing Point of Service (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 can be referred to the UPMC PFSC via phone, email, fax, and

via documentation in the PA system.

UPMC Patient Financial Services Center Point of Service Best Practices*

*Derived from various sources including: Interviews/discussions with Vendors, other

Revenue Cycle leaders, and resources such as the Advisory Board and HFMA

UPMC Patient Financial Services Center: Medical Assistance Eligibility

• 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 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


• Uninsured patients are provided with a specialist to facilitate the Medical

Assistance application process and provide assistance throughout the entire

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.

• Specialists follow up with the Medical Assistance office and the patient to verify

that all documentation is submitted.

• The process ensures that applications are submitted quickly and completely.

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.


eMA – Medical Assistance Eligibility Work Flow Tool

• eMA actively identifies the following types of patients and

automatically adds them to the workqueue for contact and financial

counseling:

• Uninsured/underinsured patients

• Individuals who have been eligible for medical assistance within the past two

years

• Pregnant women

• Children with chronic illnesses

• An average of 577 patients are referred to our internal MA eligibility

team each month


Results of MA

Eligibility Process

UPMC Patient Financial Services Center MA Eligibility Best Practices*

*Derived from various sources including: Interviews/discussions with Vendors, other

Revenue Cycle leaders, and resources such as the Advisory Board and HFMA

UPMC Patient Financial Services Center: UPMC Financial Assistance Program

• 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.


• 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


51% Increase

from FY11 to

FY13

UPMC Patient Financial Services Center: Self-Pay Collections

• When the patient enters our Self-Pay automated predicative dialer

system for collections, they are immediately segmented into one

of 5 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

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 – Previously Approved and

Currently Applying

Self-Pay Segmentation

UPMC Patient Financial Services Center Self-Pay Collections

Payment Success Rate by Segment


UPMC PSFC Opportunity Area – Elective Bad Debt

UPMC Patient Financial Services Center: Financial Assistance/Self-Pay Best Practices

Conclusion

Questions???

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