Financial options offered when admissions flagged
When the admissions nurse at University Health System in San Antonio flags an admission request because of a problem with medical necessity, she has some financial options to offer the patient, says Betty Goularte, RN, BSN, CPHQ, director of utilization management, admissions, and the emergency center.
If a patient’s admission doesn’t meet medical necessity requirements, the physician is contacted to see if other alternatives can be explored, she says. That’s the case no matter what the patient’s funding source is, she notes, and if the physician insists on going through with the admission, "we’ll ask for cash upfront."
Ideally, Sandy Taylor, RN, admission nurse coordinator, will work with the physician and patient to devise a care plan according to medical necessity, and if appropriate, get financial coverage.
"With nonfunded patients, we assess the diagnosis and plan of care and discuss it with the physician to see if it can be postponed until we find a funding source for this patient," Taylor explains. "We run them through the financial counselors to see if they qualify for Medicaid or for Carelink, a program that helps support the indigent in our county."
"If the patient is outside our county, and we can’t help financially, we will give them phone numbers of resources in other counties," Goularte says.
"We try to be the patient’s advocate," Taylor adds. "It’s a benefit to the patient and the system that we put them in the proper status."
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