UMC Audit Finds Patient Bills That Go Unpaid

LAS VEGAS -- Clark County auditors on June 14 issued a report titled University Medical Center Upfront Collections, reminding readers that the publicly funded hospital suffered more than $70 million in operational losses over the past three fiscal years.

These were among the key findings of the audit:

* No specific policy or procedure was in place to delay scheduled or medically necessary non-emergency procedures for uninsured patients until an adequate payment was made by the patient or financial assistance was obtained.

"As a result, many uninsured patients presenting for non-emergent outpatient services receive treatment prior to the hospital securing payment," the audit stated. "Those same patients also have other encounters at UMC that go unpaid. Once the uninsured patient receives their procedure before payment, there is little incentive to seek assistance or make an adequate payment. One patient had almost two years of continuous treatments without attempting to obtain assistance or make a payment."

* The Outpatient Pharmacy "allows many patients to receive their prescriptions without paying, with the cost then added to the patient's bill that there is little chance of collecting. Additionally, the emergency room does not have a discharge desk that would allow staff a last opportunity to collect payment or obtain additional information, and Patient Access Services staff had vague notes entered when registering patients and took shortcuts in documenting patient information … Besides the cost of unpaid procedures, UMC also incurs the expense of billing and collection efforts that are often unsuccessful."

* For fiscal 2011 there were 10,003 self-pay outpatients with gross charges exceeding $3 million but with outstanding balances of $2.7 million. In a review of 179 of those accounts, involving $807,363 in total charges, only $16,438 was paid by patients. Factoring in discounted charges for Clark County residents, resulting in net charges of $384,474, patient payments amounted to a little more than 4 percent.

"We found examples of patients who paid the physician for the surgery, but then did not have any funds with which to pay UMC, with the charges eventually going to bad debt," the audit stated.

Those accounts also had almost $9.8 million in additional charges from other UMC encounters that also had gone unpaid. One burn care therapy patient with more than 150 treatments over a two-year period, resulting in charges exceeding $51,000, hadn't made any payments or attempted to obtain financial assistance. Counting other charges, the patient owed $145,789. "While UMC policy allows for procedures to be delayed if a patient does not comply with financial arrangements, it is not effective," the audit stated.

* In fiscal 2011, there were 8,324 self-pay patients who didn't pay the entire cost of their prescriptions, which totaled $456,311 based on the Medicaid rate. Only 184, or 2 percent, eventually paid for their prescriptions. In 357 other accounts, write-off adjustments totaling $35,914 were made because they were take-home drugs from an inpatient stay. That left 7,783 unpaid accounts with charges of $413,892. Of those, 5,702 patients received medications that totaled less than $30. There were 3,545 patients with prescriptions under $15, for total charges of $31,616.

"Because the total bill was $14.99 or under, the charges were written off due to UMC's small balance write-off policy, and patients never even received a bill for the medication," the audit stated. "Further, the Outpatient Pharmacy has no signage in the area requesting payment from patients when picking up prescriptions."

While arguing that all self-pay prescriptions should be paid for at time of pickup, especially the ones under $30, auditors quoted the pharmacy as stating that many prescriptions are filled regardless of the ability to pay because of the federal Emergency Medical Treatment and Active Labor Act. This law requires hospitals to provide care to individuals regardless of their citizenship, ability to pay or legal status.

That said, the audit stated: "It does not take the community long to spread the word that prescriptions are free at UMC if you go through the ER (emergency room) … Not only does UMC lose out on collecting from these self-pay patients, many times it cost more to fill the prescriptions than the cost of the medication itself."

* The audit, having found no discharge desk in the emergency room, stated: "As a result, patients can walk out of the ER before the admission representatives have an opportunity to collect patient payments for insurance copayments or charges for services." There used to be a discharge desk in the emergency room but it was removed because UMC wanted to incorporate a "fast track" area for patients who "presented with a non-emergent diagnosis." The audit also stated that the emergency room visit from the self-pay patient "goes unpaid with little chance of collecting afterward."

The audit stated found 7,095 self-pay patients who had multiple encounters in the emergency room in the first six months of fiscal 2011, accounting for total charges of $19,270,918. After allowing for the Clark County resident discount of 55 percent, net charges were $8,671,913. But the hospital collected only $17,011 from those patients, representing only two-tenths of 1 percent paid on the discounted charges.

These were among the highlights of the response to the audit from Brian Brannman, the hospital's chief executive officer:

* On the issue of down payments not required at the time of non-emergency service, he wrote that the hospital "does not currently have a specific policy that determines the deposit amount nor do they have a clinical process that determines whether or not the service is non-emergent and the deferral of non-emergent care. Management agrees that such a process is necessary and a vital part of enforcing the existing policies. However, there are political realities that will need to be addressed as part of implementing any such policy."

He said UMC would create a policy for deposits and draft another policy addressing deferral of non-emergent care.

* As for self-pay patients who do not pay for prescriptions from the outpatient pharmacy, he said staff has been educated on this issue and that sign requests for payment have been made for UMC pharmacies.

* He said that UMC implemented a discharge desk in the emergency room beginning March 5. The desk will help improve collection efforts, and the hospital will begin requiring all discharged patients to stop at the discharge desk, Brannman said.

* Brannman also said the hospital would do a better job handling patient registration records, including updated demographic and insurance information for every visit.

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