PeaceHealth resets financial assistance policy to emphasize medical necessity

May 15, 2015

By BETSY TAYLOR

Patient Bikkie Uskoski says she advocated for herself "like crazy" in her effort to get health insurance, which she now has after years of piecing together coverage and losing it as her circumstances changed. PeaceHealth's charity care programs meant "everything" at times when she didn't have insurance coverage, and she needed care.

Uskoski, a Canadian who resides in Brush Prairie, Wash., since marrying her husband more than five years ago, has had several health conditions, including the removal of a goiter years ago, which her parathyroid glands did not survive. These endocrine glands usually secrete a hormone to keep the body's electrolyte levels in a certain range so the nervous and muscular systems function properly, she said.


Uskoski

Without that regulation, she experienced skeletal and muscular problems. In April, she required a hip replacement surgery, which was covered when she attained health insurance a few months ago. Before then, she credits PeaceHealth's clinicians and support staff through charity care programs for "caring so much about me; they worked so hard" on her behalf to help with her ongoing care needs.

PeaceHealth's policy and practices related to charity care are called financial assistance by the system and consist of the Bridge Assistance program for the uninsured and the Pathways program, for the insured or underinsured.

Tightening up
In 2005, Vancouver, Wash.-based PeaceHealth started its Bridge Assistance program to provide medically necessary care at a reduced cost or free of charge when payment wasn't possible through available financial resources. In the shifting health care environment of the last few years, with more patients qualifying for Medicaid or subsidized commercial insurance under the Affordable Care Act, the system took a close look at its Bridge Assistance program.

PeaceHealth remains committed to helping low-income patients with charity care or a sliding fee scale through its financial assistance programs, but it wanted to better manage its resources to help patients in need, said Dr. Robin Virgin, a family physician and medical director for PeaceHealth's primary care across the system.

Prior approval
In 2013, PeaceHealth leadership decided to implement a "prior approval requirement" for all surgeries, and high-dollar imaging and procedures to refocus the Bridge Assistance program on providing medically necessary care (See box.)

To determine if a patient qualifies for financial assistance, the patient, or someone acting on the patient's behalf, completes an application, supplying the patient's income and additional information. Those forms go to a team of financial counselors who determine if the patient qualifies for financial assistance. Once a patient is financially approved, the patient's clinical team completes an additional form requesting prior approval for services through the Bridge Assistance program, which must be accompanied by chart notes. The submission is sent to Columbia United Providers, a health plan with a contract to review applications using PeaceHealth's guidelines. A PeaceHealth medical director then issues a letter approving or denying the application, according to Virgin and Lindsay Wielkopolski, a PeaceHealth revenue cycle manager.

Once the patient qualifies financially for the Bridge Assistance program, the patient receives medically necessary care and is financially reevaluated every few months to make sure he or she is still eligible for the program. Services provided through the program include medically necessary emergency department care, inpatient hospital services, imaging and laboratory tests. It includes outpatient primary care and lab tests, but referrals are needed for specialists.

If an application is denied, the person responsible for the financial obligation may appeal by submitting additional information to the system director of hospital cycle revenue, according to PeaceHealth's website. The referring provider may appeal if coverage of a procedure or doctor's visit is denied as unnecessary.

Before and after
Virgin said the prior authorization requirement is a significant change from past practice for the health care system. Before 2013, once a patient was approved for Bridge Assistance, there wasn't enough program supervision in place to make sure the patient received only medically necessary treatment, she said.

Virgin explained that before the change, the organization was delivering more than $100 million a year in charity care based on charges for the Bridge Assistance program alone, "which was something we could not sustain." She said the system is "still evaluating the net financial effect" of how much charity care it provides as it adjusts its financial assistance offerings, but it is significantly less than it used to be. Virgin said more than 25,400 requests for diagnostic imaging, procedures and surgeries were approved through the Bridge Assistance program in 2013, compared to about 14,900 such approvals in 2014.

The drop in numbers reflects both the fact that more patients have insurance, and that the focus on reducing unnecessary procedures is having its intended effect, Virgin said.

Insurance expansion
PeaceHealth, a not-for-profit Catholic system that includes 10 medical centers and a multispecialty medical group practice with more than 800 physicians and providers, cares for patients in Washington, Oregon and Alaska. Washington and Oregon expanded their Medicaid programs under the Affordable Care Act, Alaska did not.

If a patient is uninsured but should qualify for Medicaid or premium subsidies under the Affordable Care Act, the patient's case is reviewed to evaluate whether a delay in care would put the patient at risk, Virgin explained. If a procedure can wait three months, a social worker, care manager or other care provider works with the patient to help him or her apply for commercial insurance on an insurance exchange or Medicaid. If the procedure is urgent and medically necessary, the low-income patient will be temporarily accepted into the Bridge Assistance program until insurance coverage takes effect.

High deductibles, empty pockets
For patients who have insurance, but struggle with high out-of-pocket costs, PeaceHealth started a program last year called Pathways. Wielkopolski, who works on the team that designs financial assistance policies, explained that, under Pathways, a financial counselor at PeaceHealth will evaluate the patient's income and ability to pay. She said the patient may be offered a discount on the amount owed. A patient with limited income may qualify for a 100 percent allowance, which would cover all out-of-pocket expenses such as deductibles, copays and/or coinsurance.

Financial assistance is granted to all applicants whose adjusted gross income falls at or below 200 percent of the federal poverty levels. Assets are not considered for these applicants. Assets and reasonable living expenses may be considered when determining eligibility for patients with income between 201 percent and 400 percent of the federal poverty levels. For these patients assistance is provided on a sliding scale, according to PeaceHealth's website.

Virgin said the system wants "to provide the care that is meaningful to the patients, and bridge them to other programs that are meaningful for their care." Many of its employed clinicians volunteer their services at community clinics that treat low-income patients.

Medical necessary care covered under financial assistance policy:

PeaceHealth grants financial assistance or charity care to qualified low-income individuals exclusively for medically necessary services. Medical necessity refers to care that the treating physician or clinician deems necessary for:
  • Establishing a diagnosis
  • Providing palliative, curative or restorative treatment for physical, behavioral and/or mental health conditions
  • Assisting the individual to achieve goals that a care team has established to improve the individual's functional capacity

 

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