I hope this will not be too long, and I hope no one minds that a biller is posting to the Social Worker's forum, but I really need some insight and another perspective.

I bill for two facilities, the major stockholder and medical director for both facilities being the same person.

I'm really not sure where to begin.....I'll start with this statistic: between the two clinics, a full 20% of our patients have Medicare only, with no Medigap, Medicaid, or any other policy to cover the annual Medicare deductible and coinsurance.

My boss has always been very lackadaisical about this - after all, he says, we recover it on the cost report. This has always alarmed me for many reasons - first of all, even though I still have not been able to convince him of this, we only get a very small portion, since only the 20% of the treatments is even reportable. Secondly, it takes alot more of my time, and therefore his money, to pursue collections from a patient (who has absolutely no intention to pay, or has absolutely no resources - after all, if they had either they woudl HAVE that Medigap policy) than it is to post a check from a crossover claim (or even bill a secondary claim for the ones that do not crossover). And thirdly, I was afraid, with 20% of our patients being reported on the cost report, that a red flag would be raised.

Evidently, I was not too far off on my third fear, because we were just audited, based solely on the amount of bad debt being claimed.

The social workers say dialysis patients as a whole have a sense of entitlement, due in part because they automatically get Medicare whether they are already insured or not, and partly because, since treatments keep them alive, they cannot be denied service. Of course, they can still be referred elsewhere, but evidently there are enough patients and providers both who think it is illegal to not take every patient who shows up in the office that a large percentage of patients feel like they are entitled to treatments anywhere they wish regardless of their inability (or unwillingness) to pay or seek all possible sources for third party payment.

I trust our Social Workers and their evaluation, but I also see our clinic accepting transients, transfers and new patients without anyone even having verified their insurance, whereas if any of our patients are travelling or transferring, the receiving centers ALWAYS insist on having all insurance information verified BEFORE they will even accept the patient, and many of them even ask for cash payment of the coinsurance up front for transients, regardless of whether there is verifiable secondary insurance in place.

I like both our social workers and have no doubt in their competency, but I still wonder - is this "sense of entitlement" real or imagined on their part? Or is cultivated in our clinics because there is no real sense of obligation on the part of the admissions staff to ensure all patients have adequate resources to make sure their entire bill will be satisfied in some definite manner?

And, is it normal for 20% of the census to have Medicare only? Please note, this is not 20% of the Medicare patients, this is 20% of ALL patients. Of our Medicare patients, 25% have no secondary. That just seems so excessive to me, since they can enroll regardless of pre-existing conditions within the first six months of eligibility.

If it's NOT normal, how do other clinics compel their patients to obtain a Medigap policy when they are still eligible? Are they told they will be discharged to find care elsewhere if they don't? And for new patients or patients transferring in, are they refused admission if they are not fully insured, or have other verifiable resources?

Thanks in advance for any insight anyone can offer.

First, some patients (just like some healthy people in the US) do expect society to take care of them. This is why it is so important to start from Day 1 by telling new patients that you expect them to be active participants in their care, including obtaining health insurance coverage that is available to them whenever possible.

Looking at data collected by the USRDS, it's hard to tell how many patients have Medicare only so it's hard to know if 20% without secondary coverage is high, average, or low. However, there are things that can be done to obtain better coverage for your patients.

-- It is in the clinic and patient's best interest if insurance status is verified for every incoming patient. It is best if this is done by billing personnel so they can start to establish a relationship with key people at the insurance company. Patients should be encouraged to learn what their insurance covers. The coverage a patient has can limit patients' access to transplant, transient dialysis, medications, etc. It is in the patient's best interest to get as much coverage as possible so they can get services they need.

-- All new patients that do not have full coverage should be encouraged to get Medicare supplement (Medigap) plans in the first 6 months that they have Medicare. Your dialysis clinic can contribute to the American Kidney Fund's Health Insurance Payment Program. This program was established to pay Medigap and other premiums for patients after the Office of the Inspector General ruled that dialysis clinics could not pay premiums directly.

-- Patients should be strongly encouraged to apply for Medicaid if they have low income and few assets. Medicaid can cover things that Medicare does not, like prescribed and in some cases OTC drugs, medically necessary transportation, and in some cases dental and vision services.

-- Patients who don't work should be encouraged to work if they're physically able. Your dialysis clinic could promote this by offering the best shifts to patients who are working or preparing for work. Patients should be encouraged to seek jobs with benefits. Some companies provide benefits for part-time and/or temporary workers who work enough hours.

-- Some states have a program called Medicaid Buy-in. Medicaid Buy-in allows disabled people who work to have Medicaid with higher incomes than they could have if they don't work. Medicaid in this case will cover their whole family. They may need to pay a premium if their income is higher, but the premium would be less than you or I would pay.

-- Some states have state kidney programs that may pay all or part of the cost of care for qualifying patients. If your state doesn't have a program, perhaps a coalition of patients and staff could advocate for state funding to help people with kidney disease. Perhaps your NKF affiliate would be willing to help with this.

The most important thing that you and your team (including the doctors) can do for patients is to let them know why they should care if they have insurance or not. If it doesn't help to tell them that they'll have access to more services that could help them live longer, they should also know that paying for dialysis is a responsibility of accepting treatment for kidney failure. Although I'd definitely limit use of this threat, the ESRD regulations state that non-payment of fees is one of only a few reasons a clinic can use to discharge a patient.

It's important for your clinic to maximize revenue from every possible source. With increased revenue, your clinic could afford to provide better care and things it may not currently be able to afford, like computer access for patients, exercise bikes, etc.