A Qualitative Study of Emergency Medicaid Programs from the Perspective of Hospital Stakeholders

Abstract

Background:

Uninsured patients often have poor clinical outcomes associated with lower access to care. Hospital Presumptive Eligibility (HPE) provides up to 60-day emergency Medicaid coverage for uninsured, low-income patients. After obtaining 60-day HPE, patients must file for ongoing Medicaid to sustain coverage; however, navigating HPE approval is complex. We conducted a qualitative study to understand (1) stakeholder perspectives on the application process and workflow; (2) facilitators and barriers to HPE approval to understand process improvement opportunities.

Material and Methods:

We conducted semi-structured interviews between September- December 2021 with key stakeholders (social workers, financial counselors, case managers, and private third-party vendor representatives) involved in HPE coverage determination, screening, approval, and Medicaid sustainment at our institution. We performed a team-based thematic analysis to elicit factors influencing HPE screening and approval, and recommendations for process improvement.

Results:

Study participants described the HPE application and Medicaid approval processes. Patient-level barriers included information disclosure and immigration status, inability to contact patients or next-of-kin, and knowledge gaps about insurance acquisition and sustainment. System-level barriers included technical challenges with the state HPE application portal, inadequate staffing for patient screening, and short emergency department stays that limited opportunities to initiate HPE. Stakeholders proposed improvements in education, patient outreach, and logistics.

Conclusion:

This qualitative study reveals the process of HPE approval and outlines barriers within HPE and Medicaid processing from the perspective of direct hospital stakeholders. We identified opportunities at the patient, hospital, and policy levels that could improve successful HPE application and approval rates.

INTRODUCTION

Compared with their insured counterparts, uninsured patients in the United States have higher mortality rates and reduced access to care, predisposing them to worse clinical outcomes.¹ Patients typically seek care for urgent conditions through Emergency Departments (ED), an increasingly important source of hospital admissions.² Previous studies have shown that 7 in 10 patients admitted for trauma who are uninsured face catastrophic health expenditures related to hospitalization and ongoing health services after discharge.³ Many uninsured patients are from low-income backgrounds and report high insurance costs as the reason for lack of coverage.⁴ Hospitals treating large proportions of uninsured patients, typically classified as safety-net hospitals, are also impacted financially by uncompensated care.⁵

Hospital Presumptive Eligibility (HPE), enacted in 2014 as part of the Affordable Care Act, provides emergency Medicaid coverage for uninsured, low-income patients across the US for up to 60 days.^6,7 The main goal of HPE is to enable access to acute services and offset healthcare costs, but it also provides an opportunity for patients to enroll in Medicaid and sustain coverage after HPE expires.⁵ Prior work has demonstrated early success of the HPE program. In California, for example, there are approximately 250,000 HPE enrollees annually, with Medicaid sustainment rates as high as 70% at six months following HPE approval among certain patient groups.⁸

Key stakeholders involved in the HPE processing have been identified and include hospital personnel who serve as enrollment assistants, county Medicaid representatives, and hospital-contracted vendors.⁹ Little is known, however, about how the HPE program is practically implemented by such personnel. To close this knowledge gap, this study aims to understand the processes of HPE screening, approval, and Medicaid acquisition, through interviews with key stakeholders involved in HPE workflow. We also sought to identify facilitators and barriers to workflow as well as improvement opportunities to facilitate the transition to ongoing Medicaid coverage.

METHODS

Stakeholder Interviews

Using a purposeful key informant sampling strategy, we recruited “hospital stakeholders” – hospital staff at a single institution in California directly involved with the coverage determination, screening, and approval of HPE and subsequent Medicaid sustainment.¹⁰ Hospital stakeholders were identified through the institution’s email listserv and invited via email to participate in in-depth semi-structured interviews focused on understanding the existing process and workflow of HPE applications, collaborations across teams of stakeholders, as well as barriers and facilitators to HPE approval and Medicaid sustainment. The interview guide is presented in Supplemental Table 1.

Seven study participant interviews were conducted between September and December 2021 via videoconference by two authors (A.C.B., T.J.H.): one led the conversation while the other took thematic notes and asked clarifying questions. Immediately after each interview, the interviewers met to discuss major themes and then separately summarized their observations. Each interview was audio recorded, transcribed through Zoom automatic transcriptions, and then cross-checked and de-identified by A.C.B. to ensure that the transcriptions matched the voice-recorded interviews accurately. Verbal informed consent was obtained from all interview participants and the study was approved by the Stanford Institutional Review Board. This study followed the Standards for Reporting Qualitative Research (SRQR) reporting guidelines.¹¹

Analysis

The research team consisted of a medical student (A.C.B), three surgeons with extensive health services research experience (T.J.H., L.M.K., A.M.M), and a Ph.D. trained qualitative-oriented social scientist (M.S.). We performed a rigorous team-based thematic analysis of transcripts concurrent with data collection.⁴ Then, using an inductive approach, two team members (A.C.B. and L.M.K.) independently coded all transcripts, creating two separate codebooks, each with their own unique codes. These were discussed and revised into a final version of the 18-item codebook, which was reviewed and ultimately approved by the entire analytics team. Two authors (A.C.B., L.M.K.) separately re-applied the codebook to all interviews. Each coded section was then discussed until discrepancies between coding choices were resolved and the authors reached a consensus about the appropriate code applications. We considered thematic saturation to be achieved after we had interviewed stakeholders from all parts of the HPE approval process, coded all transcriptions, and when no new themes were identified from three sequential interviews. We validated findings from coding and analysis through triangulation, member-checking, and search for disconfirming evidence.¹²

RESULTS

Participant Characteristics

A total of 7 hospital stakeholders, including two social workers, a case manager, a financial counselor, the department manager of financial counselors, a private third-party vendor representative, and a third-party Executive Director, completed interviews with the study team (Table 1). All study participants were well-trained, with at least three years of experience directly assisting patients with HPE. A wide range of respondents was approached to enable capture of each step of the process, from HPE application to approval of long-term Medicaid insurance. Although no new themes emerged after the fourth interview, each interviewee brought a unique perspective.

Table 1.

Participant Characteristics

Participant ID	Gender	Role	Years of Experience
I1	Female	Social Worker	3
I2	Female	Case Manager	3
I3	Female	Financial Counselor	12
I4	Female	Social Worker	3
I5	Female	Private Third-party Vendor Representative	5
I6	Female	Third-party Executive	3
I7	Female	Financial Counselor Dept. Manager	4

HPE Workflow and Roles

Through stakeholder interviews, we mapped the step-by-step process required to screen patients for HPE eligibility and submit their HPE application for approval (Figure 1). During emergency department (ED) registration, ED clerks determine whether patients have insurance coverage or are uninsured/self-pay. Self-pay patients are screened for HPE eligibility by financial counselors based on criteria outlined by the State of California. The MediCal (California Medicaid) Eligibility Data System (MEDS) runs patient information from the HPE application for data matching and determination. A patient must meet all the qualification criteria and fall within one group listed in Supplemental Table 2. If deemed HPE eligible, patients are approved for HPE for 30–60 days. If patients do not qualify for HPE, or if the Medicaid application is denied, social workers and case managers step in along with financial counselors to connect patients with financial assistance services for consideration of discounts applied to the total cost of care.

Fig. 1.

Process for screening uninsured patients for hospital presumptive eligibility at the time of hospitalization.

Once HPE is approved, patients may submit verification documents and an ongoing Medicaid application during the 30- to 60-day HPE period. The local county approves or denies the application within approximately 45 days. If an ongoing Medicaid application is not submitted within the HPE period, a patient will return to being uninsured after HPE. If the Medicaid application is denied, hospital stakeholders may also try to coordinate financial assistance if the patient is still hospitalized. Per the hospital’s discretion, third-party contracted vendor companies may participate in the HPE process as early as the time of screening in the ED, with involvement in some cases extending to help sustain Medicaid coverage.

Roles and Responsibilities of Hospital Stakeholders in the HPE Process

Financial Counselors:

Financial counselors are the first point of contact for patients identified as “self-pay” on arrival to the hospital. They pre-screen socio-demographic and financial information to determine HPE eligibility using the official HPE Medicaid Application form by California Health & Human Services.¹³ Initial screening and approval is obtained based on verbal information provided by patients or a next of kin who must attest to the accuracy of the information. Applications are submitted on the Medicaid website and approval by the county relies on cross-referencing patient data with county records. Financial counselors are obligated to complete online training modules lasting up to one hour to be certified and credentialed to log in to the application portal.

Social Workers & Case Managers:

Study participants pointed out that while social workers and case managers do not directly work with patients on HPE applications, they fill in gaps during the process. Social workers can help refer patients marked as “self-pay” to financial counselors for HPE screening. When patients cannot communicate adequately, they help financial counselors contact next-of-kin family members. Respondents mentioned that social workers could also refer patients with HPE for rehabilitation or long-term acute care hospital (LTACH). Moreover, case managers and social workers follow up with HPE-approved patients (mainly if they are inpatients) to ensure they follow through with applying for Medicaid. If patients are denied, social workers and case managers work with financial counselors on seeking financial assistance for patients. Social workers and case managers sometimes guide patients and families in obtaining additional health insurance or connect patients with the California Ombudsman if they have no other representation and cannot advocate for themselves.

Private Third-party Vendor Representatives:

Interviewees indicated that the private third-party vendor companies can be hired by the hospital to facilitate the HPE screening and approval process. Private third-party vendor representatives are authorized to pre-screen and obtain verbal information. They typically work seven days a week from 8 am to 4 pm; financial counselors take on full responsibility for screenings outside those hours. Private third-party vendor representatives and financial counselors work together to ensure that patients in the ED are screened for HPE eligibility. Private third-party vendor representatives must upload screening information into a specific area of the hospital’s electronic medical record system where financial counselors review data. They also obtain verification documents after HPE approval and assist patients with their application for ongoing Medicaid coverage. They can communicate the urgency of the request to the county and follow up on application status. Once a determination is made, private vendor representatives transmit the final decision to financial counselors.

County:

The interviewees reported that the HPE applications are received and cross-checked for any discrepancies by the county. The county typically processes ongoing Medicaid applications within 30–45 days and extends HPE until a determination is made on Medicaid coverage.

Ombudsman:

Social workers may contact the Ombudsman’s office to ensure patients have support to manage their Medicaid accounts. They advocate for patients who lack capacity, have a disability, or have no other identified representatives, particularly when they may have difficulty with or need to change their insurance plans.

As discussed above, hospital stakeholders perceived HPE acquisition as a multi-phase and complex process that requires a high level of collaboration to be successful. All respondents provided multiple examples of such cooperation (Table 2).

Table 2.

Collaboration Between Direct Hospital Stakeholders in the HPE Acquisition Process

Stakeholders	Exemplary Quote(s)
Financial Counselors and Social Workers / Case Managers	“We [financial counselors] work hand in hand with social work and case management as well, they’re a big part of our communication and they rely on us to have this information available and ready.” (I3, FC)
Financial Counselors and Private Third-party Vendor Representatives	“We [financial counselors] work very well together [with third-party representatives], I have not seen any hiccups or any complaints or gaps. It’s a smooth transition from financial counseling to Third-party.” (I7, FC)
Private Third-party Vendor Representatives and Financial Counselors	“Luckily, we [third-party vendors] have a strong relationship with them [financial counselors] and we have a really good team. Of course, there are little things here and there, but we are very good about, on either end from financial counseling to us, or from us to financial counseling, to let them know if there were any issues or if anything needs to be reviewed with a specific financial counselor or whatnot, but overall, we have really good communication, really good team and no complaints at all.” (I5, MD)
Private Third-party Vendor Representatives and County	“Luckily, the patient was able to get the temporary benefits, and we [Third-party] also push to get the ongoing application process a lot quicker and usually, when its patients that are under that diagnosis, a life-or-death situation, the county agrees to process the approval… [The county] agreed to go ahead and process the approval right there and so the patient was able to have the surgery and get the proper care that they need.” (I5, MD)
Social Workers / Case Managers and Financial Counselors / Private Third- party Vendor Representatives	“This is where our collaboration happened where social work either social work would get to it, or even help financial counselors or third-party [Representatives] they would reach out to us and say hey I was able to reach a daughter or son, and I was able to talk to them or sometimes we would ask the physicians or the bedside nurses, if they were able to talk to the family and emphasize the importance of bringing these documents in, and so there was a lot of collaboration it didn’t have to fall on me. But it was also my responsibility to tell everyone that ‘Hey I couldn’t get to this; can you please help me or ‘Is there anyone else who could reach out to the family?’” (I2, CM)
Social Workers and California Ombudsman	“So, I [social worker] call the Ombudsman with the patient or sometimes on their behalf, and if they lack capacity to have them [Ombudsman] be the advocate and change their plan for them.” (I4, SW)
Private Third-party Vendor Representatives and County	“Luckily, the patient was able to get the temporary benefits, and we [third-party representatives] also push to get the ongoing application process a lot quicker, and usually, when its patients that are under that diagnosis, a life-or-death situation, the county agrees to process the approval… [The county] agreed to go ahead and process the approval right there and so the patient was able to have the surgery and get the proper care that they need.” (I5, MD)

Note. FC - Financial Counselor; MD - Third-party Representative; CM - Case Manager; SW - Social Worker

Facilitators to HPE Acquisition

Team collaboration and 24/7 availability of interpreters:

According to participants, one of the biggest facilitators is team collaboration and sharing of roles, which allows hospital personnel to divide the workload and allocate additional time to patient and family encounters. In-person meetings and face-to-face conversations with patients have been cited as facilitating factors in completing applications, as well as 24/7 availability of non-English language interpreters.

Clinical complexity:

From the logistical standpoint, long hospital admissions and admission through the ED (as opposed to a transfer from an outside facility) allow for greater opportunities for patients to be screened and more time for applications to be completed with direct assistance from hospital staff. Furthermore, HPE applications for patients in complex and life-threatening medical conditions are frequently expedited for review by the county.

Private third-party vendors who liaise with patients even after discharge:

representatives stay connected with patients by checking in every two weeks with a phone call allows for a smoother process of submitting verification documents and completing the Medicaid application. Private third-party vendor representatives (I5, I6) stated that they implement many methods to stay in touch with patients, including phone calls, letters, and even visiting patients in their homes.

Barriers to HPE Acquisition and Proposed Improvements

Study participants cited a variety of barriers primarily related to patient and system factors, and proposed management strategies or improvements to address such barriers, as summarized in Table 3.

Table 3:

Facilitators to the HPE Acquisition and Full-Scope Medicaid Application Processes

Facilitators	Exemplary Quote(s)
Team collaboration and 24/7 availability of interpreters	“We have interpreters accessible to us 24/7 in the ER, so language is really not an issue.” (I3, FC) “Oh it’s a team I think we’ve built a really good rapport with the hospital staff. We have weekly calls with the social workers, case managers and talk about challenges that we have.” (I6, MD)
Clinical complexity	“I had a patient who was hit by a car, and he was stuck here for maybe 70 days so while he was here, we were able to get him from HPE to MediCal to a Managed Plan. Sometimes getting them on Managed MediCal means they’re more likely to get placed in skilled nursing or an acute rehab so seeing the entire process goes through is kind of nice to see the whole thing and see them be successful in that way. I’ve seen that maybe three times since I’ve been here.” (I4, SW)
Third-party vendors who liase with patients even after discharge	“Because we’re trying to establish contact with a patient. We do calls, evening calls we send letters and then, if all fails, we will go and knock on patient doors and say ‘Hey we’re still pending that bank statement. Can you please provide it to us?’ There is a lot of work that is done behind the scenes to get these patients eligible.” (I6, MD)

Note. FC - Financial Counselor; MD - Third-party Representative; CM - Case Manager; SW - Social Worker

Patient Factors

Knowledge gaps:

Participants cited knowledge gaps among patients and families related to completion of paperwork. They suggested that patients and families may lack education on insurance acquisition or may not understand why personal information or specific documents, like proof of income, are needed for insurance applications. Participants also indicated that patients and families often do not know additional steps required to transition from temporary HPE to Medicaid coverage, leaving patients at risk of becoming uninsured again once their HPE lapses.

Fear of information disclosure, documentation status, and citizenship:

Six of seven interview participants cited immigration status as a factor that can cause delays in screening. They indicated that undocumented status can cause hesitation to provide personal information such as social security number, address, and employment information. Patients may be concerned that providing information could place them in a vulnerable position of being exposed as undocumented, or result in negative legal consequences of using public funds, such as rejection of future permanent residency or citizenship application. Participants indicated that in some situations (e.g., minor injury), after thorough discussion, patients sometimes opt not to be screened for HPE or enrolled in Medicaid and instead decide to obtain services provided by Free Clinics.

Clinical diagnosis:

Study participants reported that if patients present to the ED incapacitated, intubated, or sedated, the resultant inability to communicate will likely hinder HPE approval. They described the need for staff to reach family members as the next-of-kin contacts to proceed with the HPE screening process. Oftentimes, families can be difficult to reach, delaying the screening process.

Loss of contact:

Study participants stated that an additional barrier to insurance coverage involves contacting patients after hospital discharge. When ED stays are very short or full-scope applications require a longer timeline, hospital stakeholders are often unable to support patients with completing all requirements and providing verification documents before losing contact with them once they leave hospital. Uninsured patients may also be experiencing housing insecurity or may not have access to a cellular phone, computer, or physical address, further inhibiting communication.

System Factors

HPE / Medicaid eligibility requirements:

According to interviewed stakeholders, HPE eligibility criteria are the most prevalent barriers to approval. If a patient makes more than the maximum household income for a particular size of household, then they are denied HPE. For example, if an individual who lives alone, is unmarried, and has no dependents makes more than $1,000 per month, then that individual does not qualify for HPE. Additionally, a patient’s ED or hospital stay must qualify as an emergency or life-threatening to qualify for HPE coverage. Special circumstances include patients with a new oncological diagnosis who need emergent outpatient surgery for life-threatening conditions. A third example of criterion barriers includes maximum approvals per year. Before Covid-19, HPE could only be granted to an individual patient once per year. This criterion has since been expanded to twice per year.

Staffing, personnel, and training:

Study participants also signaled that adequate 24/7 hospital staffing coverage is a major challenge for consistent patient screening and approval for HPE. Financial counselors reported they work seven days a week from 7 a.m. to midnight. A work queue captures patients who arrived overnight, and these patients become the priority to screen in the morning. There are circumstances where patients are discharged and lost to follow-up. In other cases, these patients may receive a call from financial counselors within the 24-hour window of their ED/hospital stay but only return the call after the window has closed, causing them to be ineligible for HPE. Participants noted that sometimes the number of financial counselors on shift is insufficient to cover the screenings needed for the self-pay population treated at the hospital. In such situations, financial counselors and private third-party vendor representatives collaborate to redistribute the workload for screening.

Technological barriers:

Study participants described specific technological and access barriers among hospital personnel to progress in the HPE submission and approval process. For example, they reported that financial counselors are the only staff members authorized to submit HPE applications directly to the state portal during initial screening. They complete training to be granted permission, and third-party representatives are currently not authorized with this privilege. Patient information obtained by third-party representatives must be uploaded to the electronic database, transposed to EPIC, then manually entered by financial counselors into the state HPE application system, leaving opportunities for error or delays in transmission or data loss. Interviewed private third-party vendor representatives (I5, I6) also mentioned that the HPE state system had been down unpredictably – causing applications to be left unsubmitted, sometimes missing the window for submission. They estimated that the state system might encounter issues 1–2 times per month, and they never know how long the system will be down for.

Proposed patient and system level improvements:

Stakeholders identified educational opportunities such as increasing education for both patients and staff about the HPE and Medicaid process, as well as providing direct call-in lines to third-party vendors and staffing of outpatient clinics or community outreach to help with Medicaid. Additionally, increased staffing and permitting additional sharing of roles could help facilitate in-hospital screening and post-discharge follow-up, as well as increase availability of stakeholders to build trust with patients. Finally, allowing private third-party vendor personnel to document directly into electronic medical records, as well as enabling retroactive approvals for longer windows could help to ease challenges posed by insufficient or overextended personnel.

DISCUSSION

This qualitative study elicited detailed perspectives and description in order to map the HPE application process and workflow and to identify facilitators, barriers, and potential solutions to processing and approving HPE applications and later sustainment of Medicaid. Limited description of HPE and Medicaid sustainment is available in the clinical literature, and this study is among the first to contribute to this important field of research. Our current findings build upon our group’s previous research by gathering insights from hospital stakeholders, such as financial counselors, social workers, and case managers involved in HPE applications and ongoing Medicaid processing.¹⁴ This approach allowed us to categorize dynamic steps in HPE processing and patient interactions with the Medicaid system.

Our prior work analyzed patient data from electronic health records, specifically financial counselor progress notes, to determine HPE screening and approval rates.¹⁴ Among trauma patients who were applying for HPE, those approved had a longer median length of stay and more severe injuries. Our current qualitative findings reinforced factors facilitating HPE approval, including longer hospital admissions and increased case complexity, which aligns with previous studies suggesting hospitals benefit from facilitating HPE applications to offset the financial burden of longer admissions.⁵

We previously found that the reason for denial in 30% of HPE applications was due to modifiable patient and system factors, such as patient refusal, loss to follow-up, and technical errors.¹⁴ In this qualitative study, we found that mistrust in the system often drives patient refusal, particularly regarding citizenship status and concerns around insurance eligibility. Stakeholders suggested that increasing one-on-one time with patients and thoroughly explaining the process can build trust and improve application outcomes, which echoes other reports.^15–19

Our study also underscores the importance of collaboration among all stakeholders in the HPE application process. With numerous moving parts, effective communication and cooperation between financial counselors, social workers, case managers, and third-party representatives are vital for successfully applying for HPE. Fostering a collaborative environment ensures a more streamlined process. For example, technological errors contribute to 2% of HPE denials¹⁴ that could be prevented. Our interviews revealed that such errors occur when county HPE or third-party portals fail to transfer information into EPIC, causing patients to miss the 24-hour submission window. Study participants offered potential solutions such as enabling private third-party vendor representatives to input screening data directly into EPIC, allowing retroactive submission and approval for applications disrupted by HPE website outages, and supporting additional staffing to streamline HPE applications and Medicaid referrals, allowing more time for patient interactions and preventing processing delays.

Our study has several limitations inherent to qualitative methodology. Our findings are not intended to be generalizable but to explore and describe the process of HPE acquisition based on the experiences and perspectives of front-line workers in this process. Our sample size was based on thematic saturation, which while appropriate in a qualitative study, would not be adequate for a quantitative study describing numerical relationships. We note that our small sample size enabled considerable time spent in each interview and the ability to collect a large volume of information on the HPE process, leading to a deeper understanding of this topic. We also applied rigorous validation techniques to enhance credibility.⁴ Finally, this study is limited to a single institution and may not describe all aspects of the HPE process or perspectives on HPE, but our interviews captured diverse perspectives from healthcare workers involved in the HPE process. Future research should explore patient experiences and investigate HPE eligibility criteria variations across states to better understand policy implications and identify improvements needed in Medicaid programs nationwide.

CONCLUSION

Our qualitative interview study revealed the process of HPE acquisition and outlined various barriers within the HPE and Medicaid system from the perspectives of hospital stakeholders. We have identified actionable measurements on a patient level and policy changes within the HPE system that may improve successful application, submission, and approval rates. Several broad policy changes such as increasing HPE screening staff and streamlining data entry protocols may allow for increased approval rates and lower costs incurred by hospitals. More specific institutional changes, such as site-specific insurance education interventions, could lead to more effective inter-departmental collaboration and trust between patients and staff. Our results highlight the potential to bridge significant gaps in health inequities secondary to lack of insurance and access to care.

Supplementary Material

1

Supplemental Table 1. Interview Guide

Supplemental Table 2. HPE Eligibility Criteria

Supplemental Table 3. Consolidated criteria for reporting qualitative studies (COREQ): 32 - Item Checklist

Table 4:

Barriers and Proposed Improvements to the HPE Acquisition and Full-Scope Medicaid Application Processes

Barriers	Exemplary Quotes	Proposed Improvements
Patient Factors
Knowledge gaps	“I don’t think that family members necessarily know how to link their loved one or family member to the full-scope medical… I think the healthcare system is a difficult system to navigate and if you are someone who has low health literacy or you’re from another country or you’ve never really interfaced with the healthcare system before it can be very difficult to navigate.” (I1, SW)	Improved educations for staff and patients about HPE and full-scope application process: “Possibly educating social workers on the differences and the application times and the processes, more regularly [would help]. I think we were probably educated when we first came in and then there’s been no follow up… Also, probably educating the rest of staff on the process, because we do get regular referrals… and they can refer directly to financial counseling.” (I4, SW) Staff in community clinics to help with full scope: “If people are in the hospital for over 30 days, then sometimes. They need someone to help… linking them to those things and the process… It is a little difficult and I don’t think that family members necessarily know how to link their loved one or family member to the to the full scope medical.” (I1, SW) Direct call line to third-party for full-scope insurance questions: “You’re screening them, you’re like, yeah you’re eligible, you got it, but then that’s all you do and there’s no effort to connect them to a full scope plan, and so I think that would be helpful. And say “oh like you can call financial counseling”, but financial counseling is not med data, it’s a different entity, so there is no one for people to call to get clarity on how this process really works.” (I1, SW):
Fear of information disclosure, documentation status, and citizenship	“I did have a family that just straight up refused to bring that information forward… the patient came from Mexico, didn’t have insurance, was here for less than a month, and got into a horrible car accident. The patient was driving under the influence and there were a lot of legal aspects, and they were just really afraid to provide any information. They were very guarded I would say, probably until like maybe two to three weeks after the patient was hospitalized, they started to trust us and know that we were working in the best interest of the patient.” (I2, CM) “What I talked to him about was ‘if you’re already pretty far along in this process, and if you think that you can manage this leg injury by going to a free clinic - you might not want to do this because this could potentially jeopardize your citizenship’, so he opted not to, he said that he thought that this injury isn’t something that’s going to require any additional surgery, it’s more just pain related.” (I4, SW)	Increasing in-person staffing to help with HPE: “I think I would say really spending time with the families and having those conversations in detail would probably help them understand why we’re looking into this, or why we’re asking this… I found that I had to really sit down with the families and initiate a family meeting and have a further discussion about the patient, why the patient’s here and why this is needed… Seeing people in person and building that trust with them and them knowing who you were and what your role was more helpful.” (I2, CM)
Clinical Factors	“They also want to talk a lot of times will want to talk to the person directly so like if someone is incapacitated, for whatever reason you’re not going to be able to talk to that person.” (I1, SW)	N/A
Loss of Contact	“We’re constantly thinking, how can we get these verifications prior to the patient leaving, and the reason we try to do that is because nine out of ten times when the patient leaves we lose contact with the patient.” (I6, MD)	Increased follow-up after discharge: “We strive to keep in close contact and build that rapport…So we’re going to be calling you every two weeks to say ‘hey have you heard anything from the county?’… If we don’t establish that rapport within that timeframe we could lose the contact with the patient, so we try to stay connected with the patient and the county at the same time.” (I6, SW)
System Factors
HPE / Medicaid Eligibility Requirements	“We do have many cases where patients do not qualify. The most recent would be a self-employed patient that came into the ER and had a $3,000 monthly income and was not married had no dependents.” (I3, FC) “You’ll have situations where patients have significant others and they don’t know their finances, while they’re here, so we can’t make that final determination if they qualify - because it is again household income and household size.” (I3, FC)	N/A
Staffing, personnel, and training	“We could miss an opportunity when it’s after hours for the financial counseling team, because we only cover the ER until midnight, seven days a week… So the only time, one could qualify for a temporary medical is that the service must be rendered that day… The other challenging thing would be is if they didn’t have enough staff for the day to get to those populations and they don’t reach out to us to say hey I need some help… So that has happened, where that communication is not done, the patient has discharged from the ER, although we get it on our work queue it’s not a guarantee we’re going to connect with that patient that day.” (I3, FC)	Increasing in-person staffing to help with HPE: See quotes from above under: “Fear of information disclosure, documentation status, and citizenship”
Technological Barriers	“We have people who come in, who get HPE, who are homeless, they don’t have cell phones. How are they supposed to follow up? There’s nowhere for them to sit down and use a computer.” (I1, SW) “I think sometimes… glitches with rulings and their modules and how data is transposed from one to the other can be a bit complicated because the risk these types of things happening.” (Third-party PAT system transposing data to EPIC in time for screening) (I3, FC)	Allowing retroactive approval when a system outage occurs: “If there’s a system outage then maybe allow the patient to go retro for that time period because, I mean we’ve had a patient, where it was like literally a week that we missed out on the HPE because of the system glitch, but this was like early on, when HPE didn’t retro because when it first started it did retro back to the beginning of the month, maybe that would be something you where patients go back to the retro at the beginning of the month.” (I6, MD) Third-party documenting into EPIC directly: “As far as an improvement, because they (third-party) have the capabilities of accessing EPIC system with Stanford, it would be helpful for them to just document in that particular system versus their own - I can see that as an opportunity. That could avoid some of these delays, and I know that their system doesn’t load the information till the batch night at 11pm and so, if I need that information before then I’m not going to get it unless I actually, physically asked them.” (I3, FC) Staff in community clinics to help with full scope: See quote from above under: “Lack of Knowledge”

Note. FC - Financial Counselor; MD - Third-party Representative; CM - Case Manager; SW - Social Worker