How to strengthen eligibility determination with a proactive approach

Missed opportunities to identify patients eligible for public health benefits and financial assistance creates friction between providers and patients. It also diminishes providers’ ability to meet their mission. Today, automated tools for screening and enrollment are making an impact.

More than one out of five people qualify for public health benefits such as Medicaid, and research shows those that receive this public health benefit are less likely to postpone or go without needed care due to cost.^[1]

Now, as the rate of uninsured Americans rises to 8%, and as 77% of physicians say many or all of their patients are affected by at least one social determinant of health (SDOH), healthcare leaders must consider: “How can we better engage patients in screening for eligible services and support?”^[2]

Leading organizations are taking a proactive approach, investing in a mix of live and automated support, in-house and outsourced, to close gaps in coverage and community services. Such gaps affect care access and decisionmaking. They also threaten health outcomes as well as a healthcare provider’s bottom line.

“With patients now responsible for a larger portion of their healthcare costs, it’s essential that we identify and enroll every eligible individual in programs that expand access and provide direct financial assistance,” said Ryan Brebner, CEO of Advocatia, which specializes in patient eligibility, resource identification and enrollment. “Doing so not only improves patient outcomes — it also helps ensure hospitals receive fuller, more reliable reimbursement for services rendered. We’ve found the financial impact that public benefits provide goes far beyond the benefit itself.”

The need for a better approach

The importance of patient engagement around Medicaid eligibility and screenings, financial assistance, ACA, charity care and community services has always been critical to building patient trust and protecting an organization’s bottom line. Now, regulatory pressures have turned up the heat for hospitals and health systems to lock down processes for screening patients for eligibility and recording the impact.

In Illinois, the Fair Patient Billing Act was amended to require hospitals to request consent from patients to screen for eligibility for public health benefits such as Medicaid as well as financial assistance under the hospital’s own policy, beginning in mid-2024.^[3] Hospitals cannot pursue collection actions against a patient unless this step has been taken and ample time has been provided for patients to respond and to act upon the financial options available.

And in North Carolina, hospitals will automatically offer charity care to eligible patients based on their income level in exchange for enhanced Medicaid payment through the state’s Healthcare Access and Stabilization Program, beginning in 2025.^[4] In a state that once recorded one of the highest rates of adults with medical debt in the nation (13.4% from 2019-2021), establishing processes not only for eligibility screening, but also for recording the amount provided in charity care each year will be essential.^[5]

“Top of mind for providers in North Carolina is, ‘How can we provide auditable information back to the state, stating that this was the amount of medical debt that was erased based on the guidelines?’” Brebner said. “While there’s some financial benefit for those hospitals, it’s also creating a lot of work for the hospitals that need a solution for capturing this data.”

Putting the right processes in place for patient eligibility, financial assistance and charity care screenings also helps eliminate payment confusion, which is vital to protecting a hospital’s reputation in a cost-sensitive environment. While most healthcare financial professionals interviewed by HFMA believe their organization does a good job of explaining patient financial matters to patients, there are still signs that patients don’t know what they owe, how their insurance works or their options for payment.^[6]

For patients who may qualify for public health benefits, financial assistance or charity care, clearing up confusion at the start of the patient financial journey ensures everyone — from patients to patient financial services staff — is on the same page regarding what’s available and what’s needed.

“Clear, proactive communication at the start of the financial journey builds trust with patients — making them more likely to engage, share needed information and follow through. When patients understand their options and feel supported, they’re far more willing to cooperate, which ultimately leads to better outcomes for both the patient and the health system,” said Laura Robbins, COO of Advocatia.

Navigating the nuances of engagement

But as healthcare revenue cycle teams know, engaging patients in conversations to determine public health benefit eligibility isn’t easy.

For one, asking patients for the income information required to establish eligibility is a sensitive discussion that can be uncomfortable for both the patient and the team member. Some patients are reluctant to share this information verbally, whether out of fear they won’t be able to receive care or a desire for privacy.

 “Propensity to pay data is helpful, but it doesn’t capture everything,” said Brebner. “If a patient was recently laid off or facing new financial stress, that’s something we typically uncover through direct engagement, and it can make all the difference.”

And some patients are harder for financial counselors to reach at the point of care. These include patients receiving care in the emergency department or outpatient settings and those seeking care in the evening or early morning, at locations and during time periods where patient financial services staff might not be available.

“In many hospitals, it’s challenging to engage patients during off-hours or in high-volume areas without on-site support,” said Brebner. “That’s where technology can fill the gap, giving patients an easy way to start the process early and helping our partners support them as far upstream as possible.”

There are also political nuances to consider depending on where the healthcare organization is located. In Georgia, for example, the state’s “Georgia Pathways to Coverage” program offers Medicaid coverage to individuals who do not qualify for traditional Medicare but have a household income of up to 100% of the federal poverty level. In 2024, this totals $25,820 per year or $2,151 per month, on average, for a family of three.

In situations like this, “It changes how you address eligibility,” said Tyler Sanders, director of patient financial services and registration at St. Joseph’s/Candler Health System in Savannah, Ga. “We had to shift our financial counseling team’s efforts away from the classic, ‘Hey, let’s have our Medicaid vendor run Medicaid eligibility,’ toward looking at, ‘Is this patient who didn’t qualify for Medicaid really a charity care patient, or could we get them on an exchange product?’”  Sanders added. “We had to develop those workflows quickly because we’ve seen a huge increase in patients who qualify for public health benefits as a result of this program.”

Finding the right approach depends on a combination of thoughtful communication and meeting patients where they are, including with the help of technology.

 “What hospitals have found is that patients who qualify for Medicaid prefer engagement through their cell phone if in-person assistance is not available,” Brebner said. One large health system on the East Coast is seeing a 76% response rate through cell phone supported assistance. It is important that hospital systems leverage dynamic technology to assist patients along their journey.

Developing the right response

How can healthcare revenue cycle teams strengthen engagement around eligibility determination and improve patient satisfaction, operational efficiency and their bottom line? Here are seven tactics to consider.

1. Offer self-service options for uninsured and underinsured patients. Provide private, always-on digital tools that allow patients to independently navigate financial assistance, Medicaid or other eligibility programs. These tools offer a convenient and informative experience that empowers patients to express financial hardship, explore their options and enroll in the right programs — without the need for immediate staff intervention. In turn, this reduces the workload for hospital staff, allowing them to focus on directly supporting more patients, improving both operational efficiency and patient satisfaction.

“Self-service options can range from a QR code in the waiting room that takes patients to an eligibility screener or automated, text-based outreach to patients the team wasn’t able to engage onsite,” Brebner said. Key to success: a solution that prepopulates forms with patient data, which ensures the data is accurate while speeding time to completion.

“By investing in tools that prepopulate forms and enable patients to sign and upload documents through their phone or email, we’ve seen hospitals and health systems increase the productivity of their patient financial services staff by 33%,” he said. “That’s critical in an era of workforce shortages.”

2. Work with physician practices — especially specialty groups — to engage patients at the point of care. At St. Joseph’s/Candler Health System, “we’ve developed a good plan to catch those patients in person at doctors’ offices. That’s the strategy we’ve seen work the best,” Sanders said. His patient financial services team prioritizes patient outreach in physician offices according to the dollar amount associated with the patient and the services they are expected to receive. 

“We started with our oncology service line and our surgery services, with a goal of hitting a 95% engagement rate,” Sanders said. “From there, we’ve expanded to other service lines, such as physical therapy, as we’ve been able to do so,” he added. The health system also strives for a 100% engagement rate among inpatients.

3. Train patient financial services staff on how to set the right tone for eligibility discussions. St. Joseph’s/Candler Health System educates team members on how to sensitively ask questions to uncover the need for benefits coverage or financial assistance for care and health services.

“I have a therapy background and a master’s in clinical mental health counseling, and I’ve found that you can ask the same question five different ways and get five responses unless you approach the conversation from a place of empathy and caring,” Sanders said. “We teach staff about ways to incorporate the right tone and delivery in having sensitive discussions with patients. In clinical areas, we sometimes ask our nurses to help us as well, especially in instances where they’ve established a relationship with the family. At the point of discharge, case managers might provide assistance.”

At one healthcare facility, leveraging Advocatia’s tested messaging strategies led to a significant improvement in patient engagement. The healthcare system increased its cold outreach response rate from 3% to 15%. 

4. Ensure that tech-based communications are hospital- or health system-branded. Such communications should make it clear that the sender is the hospital or health system. 

“This helps builds trust with patients and reinforces the credibility of the hospitals or health system” Brebner said. 

5. Strive for communications that are professional and easy to comprehend. “Make sure the eligibility screening questions are simple to understand,” Brebner said. “The more clicks it takes a person to complete an eligibility screening, the higher the chances that a patient will drop off before completing the screening. Paying attention to the preferred language of the recipient also is key. At Advocatia, screening templates are written in 75 languages.”

6. Pay attention to the timing of outreach. “It’s important that these communications take into account rules for communicating with patients — making sure communications comply with EMTALA or state regulations, for example,” Brebner said. “Patient financial services teams or their partners also should be aware of when patients might lose their eligibility so they can assist with reenrollment, if needed.”

7. Know when it’s time to invest in outside support. “We try our best to build it internally, but we’ve found we can’t do everything on our own,” Sanders said. “We have certified financial counselors that assist patients in applying for Medicaid, but we supplement their efforts with the use of a Medicaid eligibility vendor. We’ve maintained this partnership for a long time, and we reevaluate this partnership regularly to make sure they’re staying on top of things not just around eligibility. We also have secondary and tertiary vendors that support us not just with eligibility, but also insurance discovery. In a perfect world, we wouldn’t need three vendors but given the increase in volume we’ve seen — doubling in accounts receivable volume in the past three years on the Medicaid side — and how long the process of enrollment takes, we use a hybrid approach while keeping our internal team as strong as possible.”

Above all, don’t shift accounts to self-pay too quickly, Sanders said. “There’s a lot of opportunity and reimbursement that can be gained if you proactively engage patients.”  

About Advocatia

Impacting communities. Making connections. Empowering people. Advocatia is an award-winning platform built by a team with decades of experience supporting hospitals and the uninsured. Our solutions help patients navigate complex benefit enrollment while driving measurable improvements in access, patient engagement, and hospital financial outcomes. We’re passionate about helping people — and it shows. Visit our website at advocatia.io to find out more.

_{This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.}

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Footnotes

^[1]. Hinton, E., et al., KFF, “10 things to know about Medicaid,” Feb. 18, 2025.

^[2]b. Tin, A., “Number of Americans without health insurance rises in 2024, breaking streak of record-low figures,” CBS News Health Watch, Aug. 6, 2024; and 2022 survey of America’s physicians, “Part one of three: Examining how the social drivers of health affect the nation’s physicians and their patients,” The Physicians Foundation, February 2022.

^[3]. Noush, S.M., et al., “New Illinois protections against patient medical debt may also help reduce hospital bad debt,” McDermott Will & Emery, Dec. 4, 2023. 

^[4]. “North Carolina hospitals sign on to relieve Medical debt,” North Carolina office of the governor, Aug. 12, 2024.

^[5]. Raphael, J., and Hinton, E., “North Carolina’s effort to relieve medical debt,” KFF, Sept. 20, 2024.

^[6]. Williams, J., “Curing Payment Confusion,” HFMA, May 1, 2024; and Gupta, A., et al., “Unforeseen health care bills and coverage denials by health insurers in the U.S.,” The Commonwealth Fund, Aug. 1, 2024.