Shelly Brown, Harkins and Henry
Linda Carpenter, Children’s Orthopedics
Julian Caudle, Healthcare Reimbursement Solutions
Jerry Chang, KPMG
Patricia Dear, Kroll Lindquist Avey
Theresa Dair, Harkins and Henry
Peter Feste, South Fulton Medical Center
Dennis Hansen, Meridian Healthcare Staffing 
Connie Harris, Meridian Healthcare Staffing
Donna Hatcher, Children’s Healthcare of Atlanta
Paul Havey, KPMG
Rebecca Ann Haworth Campbell, OSI System, Inc.
Dotty Heffernan, Georgia Hand and Microsurgery
Lisa Ann Jagodzinski, Service Master
Debra Lee, Arthur Andersen
Patricia Liggett, Rockdale Hospital
Lacy Martin, Harkins and Henry
Michelle Minda, Ernst and Young
Julie Palmer, Harkins and Henry
Aimee Schmidt, National Data Corporation
Mona Schwarze, St. Joseph’s Candlers Health System
Ellen Silva, Harkins and Henry
Joann Simpson, Miller County Hospital
Kevin Smith, KPMG
Dwayne Fernard Taylor, South Fulton Medical Center
Kelly Thrift, Crisp, Hughes, Evans
David Whiteman, Emory Dunwoody Medical Center
Terri Witt-Perkins, Harkins and Henry
Linda Wright, Emory University Hospital
Kirk Stanley, Humana Employers Health Plan of Georgia
H.D. Cannington, Emmanuel Medical Center
Larry Magers, Elbert Memorial Hospital
Pam Arlotto, Wilcox, Arlotto, and Associates
DJ Feather, Children’s Healthcare of Atlanta
Terri Fox, St. Joseph Candler Health System
Tom Gearhart, Ernst and Young
Keith Grone, Director Collection Services
Peter Hill, Children’s Healthcare of Atlanta
Natalie Shoaf, Meridian Healthcare Staffing
Timothy Trov, Emory Healthcare

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James H. Piper, Jr.

Approximately one year ago the Managed Care Perspectives Committee updated our Managed Care Handbook. They did such an outstanding job they won the Helen M. Yerger Outstanding Achievement Award for Member Service.The Chapter won this award by submitting this manual that is entitled, "Managed Care Perspectives: A Series of Reference Tools for the Healthcare Professional." While we have had managed care manuals in the past (1993 & 1995) this is the 1st edition of a totally new reference document.

The 171-page manual includes 14 chapters, is very comprehensive and contains a wealth of knowledge. Chapters include: an introduction to managed care, payer perspectives, legal issues, regulatory environment, managed care accreditation, managed care delivery systems, financing and underwriting, market assessment, information systems management, planning and operationalizing a disease management program, clinical outcomes measures, managing with managed care, clinical staffing needs, accounting and reporting managed care arrangements.

We encourage you to purchase this dynamic tool as a study guide and reference for your managed care staff. Individual member reviews of the manual have been excellent and have resulted in numerous purchases. The manual is reasonably priced at $35 plus $3.00 for postage. Individuals throughout the hospital will find this a valuable resource.

To order a manual, you can submit your request to:

James H. Piper, Jr.
Director of Managed Care
South Fulton Medical Center
1170 Cleveland Avenue
East Point, Georgia 30344

Make checks payable to the Georgia Chapter - HFMA.  For more information, Jim can be reached at 404-305-4313.

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Question: What benefit does a facility derive when a patient is eligible for Social Security Disability and Supplemental Security Income benefits?

Individuals eligible for disability benefits receive a monthly payment from the Social Security Administration. Also, they may be eligible for medical coverage depending on their program eligibility. The individual's eligibility depends on financial factors; medical eligibility criteria are the same for both programs.

A. Supplemental Security Income (SSI)

SSI is a need based program for individuals with little or no income or substantial assets who are adjudged disabled within the meaning of the Social Security Act. Individuals eligible under the SSI program automatically are entitled to Medicaid.

Medicaid eligibility begins three months prior to their date of entitlement. This is one of the significant features of the SSI program. Treatment of a disabled person in the period immediately prior to that person's eligibility is covered by Medicaid through the retroactivity provisions. It should be noted that the date of entitlement begins the month following the month in which their disability began. As a practical matter, this means that the retroactivity of Medicaid begins two months prior to the onset of their disabling condition.

An SSI recipient receives ongoing Medicaid coverage so long as the individual receives money through the program. SSI is a need based program; eligibility is determined in part by showing financial need. In circumstances where the SSI recipient received other income or lives in the home of another individual who is not a spouse, and does not pay a pro rata share of expenses, the recipient receives a percentage of the maximum allowable benefit. So long as one dollar or more is paid, however, the individual remains Medicaid eligible.

Upon a successful SSI application, the individual will receive a Medicaid card and forms to forward to facilities that treated the recipient without reimbursement. The facility should perform routine follow ups with the recipient or his attorney (with the patient's written permission) to ensure that retroactive Medicaid is received.

B. Retirement Survivors Disability Insurance (RSD)

In contrast to the SSI program, RSDI is not a need based program. An individual becomes eligible for RSDI when that person has paid the requisite Social Security withholding taxes from income. The RSDI program works like an insurance policy in that when the requisite premiums are paid into the Social Security system, the wage earner becomes eligible for the benefits associated with RSDI. A good rule of thumb would be that a person is RSDI eligible if he worked for five or more of the ten years previous to the onset of the disability. If the disabled person is a widow and the deceased spouse accumulated the requisite quarters of coverage, the surviving spouse can be RSDI eligible based on the deceased spouse's earnings.

RSDI operates in a different manner than the SSI program. RSDI will pay monetary benefits to a qualified beneficiary after a mandatory five month waiting period. The Social Security Administration determines the date of onset of the disability. Benefits, however, are not payable under RSDI until five months from the month of eligibility elapses. For example, if an individual's disability is found to begin on May 15, 1999, his eligibility would begin June 1, 1999 and benefits payment would begin five months from the latter date, or November 1, 1999.

Individuals eligible for RSDI only are not entitled to retroactiveMedicaid, except under limited circumstances described in the next section. The RSDI recipient becomes Medicare eligible 24 months following the the month benefits begin. An RSDI application could allege disability commencing prior to the date of application. An RSDI application could allege disability commencing prior to the date of application. RSDI benefits could be payable beginning one year prior to the filing date. Such a circumstance would allow Medicare payments to begin sooner than 29 months following the month of application. Note that this is not the case for an SSI application. In SSI cases, the application date is the earliest possible onset date.

C. Concurrent Applications

While RSDI does not begin immediately, it is possible and quite common to file a concurrent application. A concurrent application is one for both SSI and RSDI. Such an application yields benefits for the disabled person and the facility treating the individual.

In a circumstance where an individual has acquired the requisite quarters of coverage to qualify for RSDI, it is possible that in the period preceding benefits accrual, the individual would be eligible for SSI. Again, in order to qualify for SSI in the instance, the individual must show financial need. If this need is shown, the individual becomes eligible for SSI for the interim period before RSDI payments begin. As stated previously, if an individual is SSI eligible, he is eligible for Medicaid coverage.

There are applications in which the individual's RSDI benefit is small enough that it could be supplemented by SSI. Generally RSDI benefits exceed the $512 per month maximum payable under the SSI program. In circumstances where the RSDI benefit does not exceed $512 and financial need is otherwise shown, SSI will supplement the RSDI payment. Again, since SSI payments are being made, Medicaid coverage accompanies this eligibility.

As with an SSI only application, a successful concurrent application in which SSI as well as RSDI benefits are paid will allow the facility the opportunity to receive Medicaid payments by virtue of the SSI eligibility. Also, it allows the facility to procure Medicaid reimbursement for treatment occurring in the two months prior to the date disability began.

D. Other Important Information

In circumstances where RSDI only is approved for the individual, Medicare coverage does not help the facility recoup the costs associated with treating the patient at the onset of their disability or shortly thereafter. While not automatically eligible through RSDI, however, medical bills may be reimbursed by Medicaid under the Medically Needy program. For people adjudged disabled under the RSDI program but are over resource for SSI, and individual able to prove financial need based on income and asset limitations may qualify for this form of Medicaid. In this circumstance, the individual would need to receive treatment and go to the local DFCS office to get Medicaid relief for these medical expenses.

If neither Medicare nor Medicaid are available, the RSDI recipient will receive income which could be used to pay down past due medical bills. A patient is likely to be more amenable to making arrangements with a hospital representative when that representative provides information on Social Security Disability benefit programs available to the patient.

Question: How can one identify a patient who may be eligible for disability benefits?

The medical criteria needed for a disability determination by the Social Security Administration are the same for SSI and RSDI. Generally, a person is considered disabled within the meaning of the Social Security Act if that person is unable to engage in any substantial gainful activity by virtue of a physical or mental impairment, or combination of impairments, which has lasted or is expected to last for a period exceeding twelve months or is likely to result in death.

Even though other factors are used in determining whether an individual is disabled within the meaning of the Social Security Act, a treating facility should focus on the medical impairments of the patient. In particular, the facility should review the severity of the condition and the expected duration of the impairment.

The reimbursement specialist or other person responsible for receivables should determine the severity of the condition. Patients with heart problems, for example, vary drastically in the extent to which their condition limits them. The hospital representative should look to the extent of the limitations involved and the degree of fatigue and pain accompanying the condition.

The durational requirements for a disability determination often present problems. There are many severe conditions that will resolve within twelve months, or at least resolve to the extent the patient is able to return to work. Victims of strokes and aneurysms present evaluation problems because recovery from these conditions varies dramatically. When in doubt, it is advisable to file an application as it always can be withdrawn.

A couple of rules of thumb help in the determination of a viable disability applicant. The older the individual, the more likely the individual will be approved. This is because older individuals are considered less able to successfully adjust to new occupations. The same is true for individuals with lower levels of education and those with work experience in unskilled or semiskilled jobs where there are no transferable skills.

The Social Security disability adjudication process often frustrates people into abandoning their application. With any application comes a significant amount of paperwork to be completed often requiring information beyond the scope of the claimant's knowledge. In addition, with the exception of the more severe impairments, claimant's are likely to be denied at least once before their application is successful. Often it is necessary for a claimant to go through a hearing before a United State Administrative Law Judge. The uninitiated are likely to relinquish their claim after their first or second denials without resorting to the administrative hearing, where far more cases are approved. Because of this, there should be someone to help navigate the claimant through the process, encouraging them to fight through the frustration and aiding with reference information helpful to the claim.

Claimants can hire attorneys to represent their interests in Social Security disability cases. The Social Security Administration controls the manner in which attorneys are paid to avoid abuses. These controls include fees on a contingency basis and limits on the overall fee payable. Whether or not an attorney is hired to provide legal support, the facility should do all it can to ensure that the claimant persevere through the process.

Michael Rosetti, J.D.
Feiler & Associates
Marietta, Georgia

Please address legal inquiries for future Scroll consideration to:

"Ask An Attorney"
Feiler & Associates
2629 Sandy Plains Road
Suite 201
Marietta, GA 30066

The Scroll Committee reserves the right to screen and publish inquiries.

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Lee Evins
Wellstar Health Systems, Inc.
770-956-6437

Tim Beatty
Wellstar Health Systems, Inc.
770-792-5039

Carmen Sessoms
McKesson HBOC

Patty Booth
Athens Regional Hospital
Information Systems
706-552-5430

Terri Tillery
Director, Marketing & Client Relations
Clark & Mascaro, P.C.
404-231-5771