Why Cook hospitals are losing millionsPoor record-keeping gives free ride to those who can pay
Sunday, February 11, 2007
by Judith Graham
No one seemed to care that Mary Smith had health insurance when she sought medical care from Cook County last year.
At the Hayes Health Center on the South Side, a misinformed clerk told her, "You know, we don't take insurance," when Smith presented a Blue Cross and Blue Shield card.
At later visits to Stroger Hospital, overworked staff didn't inquire if Smith, 66, had medical coverage. "They didn't ask me, so I didn't offer," said Smith, a former custodian who also has Medicare.
Although her experience is not universal, it's not an aberration either. Cook County's three hospitals and 28 clinics often fail to collect payment for medical services--even when patients have insurance and qualify for government health plans, according to almost two dozen interviews with officials, doctors, nurses and other experts.
As a result, taxpayers are underwriting millions of dollars--perhaps tens of millions--in medical care annually for people who could contribute to the county's coffers instead of being a financial drain on the public health system.
Exactly how much money is at stake isn't clear, because no one at the Cook County Bureau of Health Services knows how many patients listed as uninsured in fact have coverage from Medicaid, Medicare or private insurers.
But in the last year alone, patient fees were $97 million less than projected, and $250 million in medical services weren't billed, according to estimates released last month.
Under the threat of a proposed budget requiring significant cuts in medical services, the bureau's new leadership has acknowledged the problem and promised a financial overhaul.
"It's a mess and needs to be fixed," county health chief Dr. Robert Simon told county commissioners on Jan. 31.
"If we do not have the revenue coming in, we're not going to be able to take care of the people who need care," warned Tom Glaser, the health bureau's new chief operating officer.
Many patients are frustrated by the health bureau's financial practices. Robert Breving, 63, said he has tried to get the county to bill his health insurer, Cigna, for three years.
"I come in, I hand in my card, they make a copy. This happens seven, eight times over the past three years, but never once has my insurance been billed," Breving said. "Every time I go in, I say, `You've got a problem here.' And the clerk looks at me and says, `We don't bill. That's a different department.'"
One woman wrote to county Commissioner Larry Suffredin to tell him the Stroger Hospital staff had repeatedly billed her for an gastrointestinal exam last November instead of sending the invoice to her insurer as she had requested.
When she went to Stroger's finance office, the woman wrote, she was told that the staffer who deals with last names beginning with "L" wasn't in and she'd have to return. "Incompetence," she fumed in the note to Suffredin, who shared her letter with the Tribune.
In well-functioning medical centers, patients are asked if they have insurance when they walk in the door. Financial counselors are available to discuss how payment will be made. Counselors try to make sure eligible patients are enrolled in public programs such as Medicaid or Medicare.
Doctors do their part by filling out forms that specify the services they've delivered. Other staffers keep track of extras administered, such as drugs or other supplies. The forms go to clerks who make sure each item to be billed is matched correctly with a code indicating the charge. Then, bills are prepared, sent out and tracked to make sure payments come in on time.
Medicaid rejects many bills
The reality at the county health bureau is different. Take it from Glaser, who was willing to talk about a long list of inadequacies in an unusually frank interview.
"We don't have enough front-end registration people," Glaser said, acknowledging that poorly trained staff members routinely fail to collect data needed for billing purposes from incoming patients. As a result, 39 percent of bills submitted to Medicaid--the government's health plan for the poor--are rejected.
At the busy orthopedic clinic at Provident Hospital, Dr. Daniel Ivankovich gets no help signing up patients for government health programs, even though most of the patients are disabled and could qualify. Because financial counselors aren't available, Ivankovich said he does it himself when he can.
As for paper "encounter" forms--the sheets with tiny boxes that physicians typically check off during office visits--they don't list many procedures eligible for payment, and the codes used to charge for services are outdated, several county doctors reported.
Bills from Ivankovich's clinic don't cover expensive items such as crutches, casts and special braces, which are given out free even though many could be charged to Medicaid and Medicare. His own services are billed at the clinic rate, not reflecting the fact that he's a surgeon and eligible for higher payments, he said.
"Give me a social worker and someone to help with the paperwork, and I could generate millions of dollars from Medicaid and Medicare a year," Ivankovich said.
In addition, county clinics continue to hand out free prescriptions to patients who have coverage through Medicare's 1 1/2-year-old drug program.
Perhaps the most troubling sign of financial negligence at the health bureau is the failure to send out bills and collect payment for services delivered. Several sources report that doctors' encounter forms have piled up in rooms at Provident Hospital and Stroger Hospital, either ignored altogether or tossed aside if judged difficult to deal with.
Dr. Terry Conway, former head of the clinic network at the county system, tells of going to one of these rooms almost five years ago to check on encounter forms that finance staff members claimed hadn't been filled out correctly by physicians.
"It wasn't just a pile," Conway said. "It was a wall of boxes of encounter forms, 6 feet high by 12 feet long."
A check of the boxes indicated about 25 percent of the forms were at least a year old--meaning they could no longer be submitted for reimbursement, Conway said.
Bills for the county's clinics, which handle about 750,000 visits a year, have been especially neglected. Finance staff members appear to do a better job of seeking payment for expensive hospital stays and procedures, Glaser said.
Last year the health bureau decided on a new financial strategy: It would send invoices to patients and allow them to ask for discounts if their incomes were below a certain level.
Problems quickly developed. The understaffed financial aid office was unable to handle patients' requests for assistance. Phones went unanswered. Requests to mail out financial aid forms were ignored. "There are long lines ... it's a big problem," Glaser acknowledged.
Ordeal over $1,600 bill
Elaine Stock, 59, who is uninsured and unemployed, was astounded when she got a $1,600 bill after her doctor ordered a cardiac stress test last November. Like many county patients, she had assumed she would get free care because of her low income.
Stock called and was told she'd have to come in to the financial aid office to talk to a counselor. "I show up at 8 a.m. and I'm told it's too late--they'd already signed up the maximum number of people. They tell me you need proof of income, a state ID, a birth certificate, and, `Fill out this form and come back.'
"Three weeks later, this is in January, I'm there at 6:15 a.m. lining up and I finally get to see someone around noon. That's when they say, `You forgot to bring in the utility bill.' I talked them out of it, but I didn't get out of there until 4 p.m."
Only after all this did the finance staff write off the entire $1,600 charge.
Glaser attributes the problems to a dysfunctional culture at the bureau, which he describes as "we're charity care, we do things free" and "it's not worth the effort" to try to collect payments.
"That has to change," he said.
Some experts also believe the health bureau became overreliant on a huge federal cash infusion known as the "intergovernmental transfer" and began neglecting the basics of collecting payment.
The mistake was thinking that the flush times would last. But Congress passed legislation in 2000 that gradually restricted the payments, and new government regulations soon may eliminate virtually all of the funding.
Going forward, Glaser said he hopes to add more staff to the financial aid office and tackle other problems head-on.
Glaser also plans to make better use of three consultants hired last year to help the health bureau collect more revenue. So far, consultants have been trying to gather information on patients and insurance months after they were served--an inefficient method, Glaser said. He plans to ask consultants to deal with patients when they come in for care, beginning in the next several months.
Officials also plan to hire a consultant to recover payments from Medicare drug plans, but the deal hasn't been completed.
Expensive computer programs meant to solve some of the billing problems haven't been working as expected, in part because data is getting lost when it's transferred from clinical settings to the finance department. That will be fixed, Glaser promised.
But some have their doubts. A consulting firm the county plans to hire to help enhance revenues, ACS Healthcare Solutions, recently came under fire in Las Vegas for work it did for University Medical Center. With an ACS contract in place, the Las Vegas hospital lost $34.3 million last year, far more than expected.
Simon, the health bureau's chief, said he and Glaser had checked multiple references for ACS and all indicated the firm was qualified to help the county out of its financial difficulties.