Guest blog post by Rob Watkins, Staff Attorney, Tennessee Justice Center (TJC)

Medical debt is the leading cause of personal bankruptcy nationally and is often triggered by a family’s or individual’s lack of adequate health insurance coverage. Tennessee is no exception. In fact, it leads the nation in medical bankruptcies.

This has serious consequences for both families and hospitals. Not having health insurance has a devastating impact on a family’s health and financial well-being. The other side of the same coin is unreimbursed costs for providers. While many hospitals are highly profitable, small, rural hospitals are struggling under the burden of uncompensated care. Tennessee is one of those states, with large rural areas where uninsured rates remain high.

The recent COVID-19 pandemic has made a bad situation even worse. While the federal government has promised to cover COVID-19-related costs, there are significant concerns about how that commitment is going to play out on the ground, given the complexity of medical coding and the multiple health factors many medically vulnerable patients have. We believe the financial burdens created by this will affect families long after the public health emergency is lifted.

For the last two years the Tennessee Justice Center (TJC), with the help of a generous grant from the Annie E. Casey Foundation to participate in the Southern Partnership to Reduce Debt (SPRD) , has worked to reduce the impact of medical debt on the financial security of Tennesseans.

Below is a summary of our efforts that we hope will aid you and your organizations as you help those struggling with medical debt.

The Scope of the Work

The purpose of our work is to prevent or reduce patients’ medical debt by increasing coverage for uninsured patients through meaningful collaborations with hospitals. Hospitals are often on the front lines, routinely working with uninsured patients. At the same time, they have a financial interest in finding coverage for patients, since more coverage means fewer unreimbursed costs that could hurt hospitals financially. This creates a common cause for patients and hospitals.

Recognizing that the sickest five percent of the population incurs over half of all medical expenses, we also focus primarily on obtaining Medicaid or Children’s Health Insurance Program (CHIP) coverage for these high-cost patients for whom insurance is the most critically needed.

We achieve results by focusing our efforts on the following activities:

We look for coverage opportunities that are often overlooked. Health insurance in this country is  overly complex, and Medicaid is no exception. We educated ourselves on the coverage options for our uninsured population and discovered that Medicaid offers some programs that are not commonly tapped.  They were great ways to find coverage for high-cost patients.

It is extremely important to keep in mind that every state’s Medicaid program is different. What we learned about how TennCare–Tennessee’s Medicaid program–works won’t necessarily apply to your state. Getting up to speed on the unique mechanics of your state Medicaid program is critical.

We provide training on coverage options available to patients. We took the knowledge that we learned about coverage and shared it with frontline staff at the hospitals we worked with through training programs and other forms of technical assistance to make it easier for them to find coverage options for uninsured patients. We also provided them with the use of our benefits screening tool called AskJane!

For this to be successful, or even possible, relationship building is key. Hospitals are big, with many levels of administration. Figure out who makes the important decisions and invest time in creating a working relationship. Those decisionmakers can point out the barriers to coverage they often encounter. Building relationships is also important to do with outside vendors who are often brought into hospitals to work on coverage and payment issues. If you present yourself as another resource, particularly for the challenging cases, they are less likely to view you as competition.  

We use the legal system for difficult cases. There are times we believe a patient is eligible for coverage under a certain Medicaid program but TennCare denies coverage. To address these situations, TJC established partnerships with hospitals who refer patients to us for legal representation. We then file eligibility appeals, negotiate with TennCare counsel and participate in administrative hearings for these patients.

This avenue is especially important when you have a state Medicaid office that is less cooperative. Backing up claims by using the legal system gives you another opportunity for relief.

The Results

In 2019, we eliminated $847,506 in medical debt for individual patients. Our work also helped uncover errors that TennCare was making when it came to interpreting eligibility rules, and those mistakes were rectified. We conservatively estimate this correction will prevent the accumulation of more than $31.5 million in medical debt annually by low-income patients who are hospitalized for more than 30 days.

We also created a valuable resource, TennCare Enrollment Strategies for 2020: Best Practices Guide for Hospitals, in which we identify challenges specific to hospitals and share strategies to maximize enrollments, including a step-by-step process frontline staff could use to solve difficult problems.

You can learn more about our initiative by reading our medical debt case study, Using Medicaid Coverage to Prevent Medical Debt

The Impact of COVID-19

As one might expect, when the pandemic hit, the demand for our services increased. In addition to the typical challenges of enrolling in Medicaid, our clients are concerned about how stimulus relief like supplemental unemployment benefits and economic impact payments would affect their eligibility. The pandemic also expanded who we serve. With unemployment claims rivaling Great Depression levels, the number of Tennesseans becoming eligible for public health coverage and nutrition benefits has increased significantly. Since many are unfamiliar with the state’s safety net programs, educating Tennesseans and those who serve them is a new priority.

In response, we have compiled an extensive list of resources available to individuals and families who desperately need assistance. We also routinely educate fellow advocacy groups on how to help apply for benefits. You can find the information here.

Looking Ahead

We have learned a lot from this project over the past few years. We have managed to lower medical costs and find coverage for a significant number of people, but our work is far from over. In the coming months, we plan to partner with another hospital, look for ways to improve provider charity care services and explore the impact of COVID-19 on medical debt burdens.

Our work has highlighted the vital role that health coverage plays in preventing medical debt, and we are grateful for the Annie E. Casey Foundation’s continued support of this important work.

If you have additional questions about TJC’s efforts to reduce the impact of medical debt on financial security, please contact Rob Watkins at [email protected].