District of Columbia:

Barriers to Medicaid Enrollment Contribute to Hospital Uncompensated Care

HRD-93-28: Published: Dec 29, 1992. Publicly Released: Jan 28, 1993.

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William J. Scanlon
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Pursuant to a congressional request, GAO reviewed the District of Columbia's (DC) Medicaid program and uncompensated hospital care in DC, focusing on the: (1) extent of DC hospitals' problems with uncompensated care; (2) Medicaid enrollment process and its relationship to Medicaid reimbursement and uncompensated care; and (3) potential barriers to enrollment in the DC Medicaid enrollment process.

GAO found that: (1) in 1990, the average uncompensated care burden for DC hospitals totalled $228 million, 10.6 percent of total operating costs, which was more than twice the national average; (2) DC hospitals were finding it more difficult to manage uncompensated care because of the shift in patients' insurance coverage from full charge plans to discount and government plans, hospitals' financial instability, and the increase in emergency care for uninsured patients; (3) DC hospitals' operating margins have declined nearly 10 percent in 1990; (4) because they had difficulty receiving all Medicaid revenues to which they were entitled, DC hospitals contracted with private firms to assist uninsured Medicaid-eligible patients in enrolling in the Medicaid program, since the DC government did not provide enough direct assistance to such patients; (5) factors contributing to qualified patients failing to establish Medicaid eligibility and hospitals needing to use private firms include a long, complex Medicaid application and documentation process, a lack of meaningful incentives for patients to comply with application requirements, and an over-stressed, under-funded DC social services system; and (6) although it is implementing an automated eligibility system for its assistance programs, the DC government has done little to increase the Medicaid enrollment of eligible hospital patients.

Recommendation for Executive Action

  1. Status: Closed - Implemented

    Comments: Two Medicaid eligibility workers are stationed at D.C. General Hospital to process Medicaid applications. A pilot project with eligibility workers at public health clinics was terminated after 13 months when it was determined that their caseload was insufficient to justify continuation. Hospital employees at all 7 disproportionate share hospitals in the District have been trained to prepare Medicaid applications and assist applicants. Completed applications are then forwarded to the District's central Medicaid eligibility unit for official approval. Salary and benefit costs for these employees has been determined to be an allowable administrative expense for the hospitals' Medicaid cost reporting purposes.

    Recommendation: The Mayor of the District of Columbia should establish a demonstration or pilot project focusing on the enrollment of Medicaid-eligible individuals at hospitals. Such a project could: (1) identify and describe the population or subpopulations of eligible patients having the most difficulty getting enrolled; (2) identify the assistance needs of these groups; and (3) test methods of providing these patients with needed assistance through outstationing of eligibility workers and other means.

    Agency Affected: District of Columbia


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