How Cook County Health and Hospitals navigates RCM as a safety-net provider

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Safety-net hospitals and health systems face unique revenue cycle challenges, as they provide care for millions of vulnerable, uninsured patients burdened by economic hardship.

One such organization is Chicago-based Cook County Health and Hospitals System, a safety-net healthcare provider for residents of Cook County. More than 41 percent of the health system's patients have Medicaid coverage, and more than 37 percent are uninsured.

Even with expanded health coverage under the ACA, serving this patient population comes with a number of challenges, according to Doug Elwell, deputy CEO of finance and strategy at CCHHS.

"With the implementation of the ACA, many more patients now have health coverage and more options for care," he says. "This is extremely positive for our patients and the precise intent of healthcare reform. However, it comes at a price for safety-net providers as we must create a more robust revenue cycle process to receive payment from a multitude of managed care organizations for the care we provide."

Mr. Elwell recently spoke to Becker's Hospital Review in detail about these challenges and how they impact revenue cycle management.

Note: Interview has been lightly edited for length and clarity.

Question: What challenges does CCHHS face in caring for its patient population?

Doug Elwell: Our patients have unique issues over and above their healthcare issues. Many of them have extremely complicated situations. For instance, the patient may have a literacy issue. So giving them their medication without fully explaining it to them doesn't work. Some of our patients are homeless. Giving them a medication that requires refrigeration doesn't work very well. So you really have to understand their circumstances. Some have behavioral health issues on top of their underlying medical condition. Additionally, many of our patients are not literate in the language they speak. Many of our patients also live in areas that are underserved by public transportation, and getting a ride from a friend or family member is not always an option. Maybe everything is set up, they're really sick, they need to get to the hospital, but their transportation gets cancelled. Just making it to an appointment with a physician can be a challenge.

Safety-net hospitals generally see more complex patients with complicated, often undertreated, medical conditions that are compounded by poor socioeconomic determinants of health, like access to food and housing. We have developed over the last 180 years an ability to care for these patients. Safety-net hospitals primarily treat the indigent and new immigrants, and we've been doing it for generations. Where the immigrants come from changes, but the fact that they're struggling to figure out how to survive, how to prosper in this community, stays the same.

Q: How are your billing and collection practices tailored to your patient population?

DE: Because of the population we serve, billing is a little more challenging for us. For a long time, almost two-thirds of our patients didn't pay us at all or were Medicaid members where we just sent the bill to the state's Medicaid office. Under fee-for-service Medicaid, we were reimbursed on per diems that were all inclusive. Coding didn't matter. Hospitals around us developed a lot of coding expertise, which was important for their reimbursement from commercial insurers. We didn't develop a lot of that. We had a very limited need for coding, and wouldn't have seen a return on investment in developing those capabilities in a fee-for-service environment. Our physicians spent all their time treating the patient not worrying about coding. But as many states move from fee-for-service Medicaid to Medicaid managed care, safety-net hospitals now have to work closely with managed care organizations to receive reimbursement for services they provide to Medicaid members.

For us, this means that instead of sending all of our Medicaid bills to the Illinois Medicaid office, we now have to submit them to eight different managed care organizations. These managed care organizations all have their own pre-authorization, approval and payment processes. This has required us to build out more robust coding and billing capabilities internally so we can receive appropriate reimbursement while still providing the same level of care we've always provided.

Q: CCHHS will soon kick off a new coordinated health program for the uninsured. How does that work and what impact does it have on the revenue cycle?

DE: There are two big changes with this program: First, most people enter our charity care program only after they are very ill. We want to engage those patients before they become sick and when they may not otherwise have a source for primary care. Second, in our current program, a patient can receive free or discounted care through our health system based on their income level, but they don't receive much guidance on how, where or when to seek care. In the new program our goal is to be proactive in educating each patient about how to access the health system and the benefits of primary care. We will align them with a medical home that will know them as an individual and their medical conditions. They will get a membership card, a guidebook and a care manager. We anticipate having 40,000 members in the program in the first year. Patients who earn up to 200 percent of the federal poverty level and are not otherwise eligible for public insurance will be eligible. Members will be able to receive care at any CCHHS facility, largely free of charge and with only nominal co-pays for dental and pharmacy.

CCHHS spends between $400 million and $500 million annually on uncompensated care. Our goal with this program is to provide more less-expensive primary care and reduce the need for expensive, preventable hospital care. As the program matures, we hope our costs will go down because we will be able to keep our patients healthier. While the billing and coding implications are minimal, overall we hope to see our uncompensated care costs decrease, but it will take some time.

This represents a change in how we're looking at the world and how we can get out in front with that group of uninsured patients to help keep them healthier and do the same types of things we do for our Medicaid patients and our Medicare patients.

Q: How has the ongoing opioid epidemic impacted CCHHS and its patients?

DE: Our emergency departments saw about 1,000 opioid-related visits per year a decade ago. Last year, we had about 5,000 opioid-related visits to our EDs and are on pace to see that volume this year as well. That obviously has a big impact, not only on our clinical operations but also for our patients who are increasingly having negative health outcomes related to prescription and illicit opioid use.

CCHHS also provides healthcare services in the county jail. Each year we treat more than 10,000 patients in our opioid detox program at the jail. Because we know people who have recently gone through detox are at a much higher risk for overdose, we are working with the county sheriff to identify individuals who may be at-risk for an opioid overdose. We provide those patients with training on naloxone use and give them a naloxone kit upon discharge.

We are also developing medication-assisted treatment programs at all of our health centers in the next year so our providers can best treat people with alcohol and drug dependence in the community. Additionally, we're training partner federally qualified health centers to do the same thing. We're providing clinical oversight for their medication-assisted treatment programs so we can expand access to these important services. Over the past few years, we have shifted a number of our resources to the behavioral health area so we can battle this epidemic.


More articles on revenue cycle management:

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RCM tip of the day: Update proprietary forms with new ICD-10 codes
This week's 5 must-reads for hospital RCM leaders

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