Roughly half of the patients Zufall Health Center serves in New Jersey are uninsured. But requirements to get federal payment for COVID-19 testing and treatment for those patients have given Zufall CEO Eva Turbiner pause.
New Jersey has the second-highest number of COVID-19 deaths in the country, but the state hasn't yet taken steps to ensure COVID-19 testing and treatment for uninsured patients are readily reimbursable by Medicaid. Healthcare providers can apply for federal reimbursement, but the claim forms ask for Social Security numbers that Zufall doesn't always collect.
Some say the requirement needlessly forces healthcare providers to either ask for information that could undermine patient trust, or forgo reimbursement.
"We're between a rock and a hard place. We have not made any final decision, and we have not billed through the portal yet," Turbiner said.
Some community health centers are concerned about the collection of personal patient data on their patients who are uninsured, including some unauthorized immigrants, by a federal government program. Industry experts said Social Security numbers have generally fallen out of favor as patient identifiers in the healthcare sector.
The federal government will not receive any patient data from UnitedHealth Group, which administers the claims reimbursement program, a Health Resources and Services Administration spokesman said.
Community health centers are in a particularly tough spot because they are required to serve any patient who comes through their doors, regardless of ability to pay or immigration status. That means some clinics don't generally ask patients for their Social Security numbers.
"It's a don't ask, don't tell sort of thing," said a source familiar with the issue.
The HRSA COVID-19 treatment and testing reimbursement program is funded by a $2 billion testing fund earmarked by Congress and an undisclosed portion of the $175 billion Provider Relief Fund lawmakers created to help healthcare providers deal with lost revenue and expenses due to COVID-19.
The funds are available for care provided to unauthorized immigrants who are uninsured, but some advocates say that asking for Social Security numbers could discourage immigrants from seeking needed care in the midst of a pandemic.
"We all know that even the inquiry alone can chill people and frighten them, and make them think this is no longer a safe place for them," said Shelby Gonzales, director of immigration policy at the Center on Budget and Policy Priorities.
A recent study by the Urban Institute found nearly 1 in 3 low-income, immigrant families with children forgo public benefits like health coverage or food stamps out of fear that it could jeopardize their permanent residency status. That's an increase from 1 in 5 families last year.
Guidance on the HRSA website says that healthcare providers are asked to provide a Social Security and state identification or driver's license number for each patient. If they can't, the provider has to attest that they attempted to capture the information from the patient at the time of service or did not have contact with the patient. Claims submitted without one of the identification numbers may take longer to verify, according to the guidance.
Some front-line providers are concerned that submitting claims without Social Security numbers could flag personal data of unauthorized immigrants if the federal government obtained the information. However, they've been reluctant to publicly voice their concerns for fear of drawing attention to their provision of healthcare services to unauthorized immigrants.
A HRSA spokesperson said UnitedHealth Group uses the identification numbers to validate whether patients have other insurance that would disqualify them for receiving funds meant for uninsured patients, and that the federal government does not receive personal patient data.
The preliminary contract between HRSA and UnitedHealth also prohibits the health insurer from publishing or disseminating identifiable information about patients and requires UnitedHealth to get government permission for use of patient data other than its original purpose, HRSA said. The parties are required to reach a final contract by October.
Before the coronavirus pandemic, President Donald Trump derided Democratic presidential candidates for their support of providing healthcare coverage to unauthorized immigrants, and his administration has advanced policies that discourage legally present immigrants from using public benefits.
Some hospital leaders are concerned that attention to the issue of submitting Social Security numbers could result in HRSA making the program more restrictive based on immigration status, which they said would have deleterious effects on both individuals and public health.
But even lab giants LabCorp and Quest Diagnostics said many of the claims they are submitting to HRSA don't include Social Security numbers, as their use as a healthcare identifier has waned.
"Because we do not routinely receive this information, and we do not have direct patient access at the time the lab test is ordered, we cannot consistently submit Social Security numbers as part of the HRSA claims submission process," a LabCorp spokesperson said in a statement.
Quest said it receives Social Security numbers for a minority of tests, and the company submits the information to HRSA when it is available.
Privacy and data ethics consultant Michelle De Mooy said one of the reasons to reduce the use of Social Security numbers as healthcare identifiers is that the healthcare sector can be the target of malicious attacks.
"When personal data is breached, criminals are invariably looking for SSNs because it is so identifiable and opens the door to all kinds of fraud, including healthcare, credit and housing," De Mooy said.
Some community health centers, including Vecino Health Centers in Houston and members of the Pennsylvania Association of Community Health Centers, have submitted claims to HRSA without concern about data collection.
With the variety of testing reimbursement options available through Medicaid and state programs, the utilization of the HRSA fund overall is fairly low. As of Thursday, HRSA has approved $31.6 million in reimbursement for testing—1.6% of available funds—and $155 million for treatment.
While community health centers received some designated federal funding through COVID-19 relief packages, Turbiner says it didn't fully cover the costs of testing at Zufall Health. Community health centers are also required to maximize outside reimbursement opportunities before tapping into their core federal grant funding.
There's a chance the testing costs could eventually be reimbursed by the state, or elsewhere, but those pathways remain uncertain.
Tom Hester, a spokesperson for the New Jersey Department of Human Services, said the department is in discussions with CMS about how the state might adopt a new Medicaid eligibility pathway that would provide COVID-19 testing for the uninsured with federal funds.
Continuation of the HRSA funding for testing and treatment is still "essential," Hester said. The optional Medicaid pathway is not available to unauthorized immigrants and only covers COVID-19 testing, not treatment.
In the meantime, Zufall Health's Turbiner said it's wonderful that the federal government has stepped in to help fill the gap. But she's still concerned about the finer details of the process and how patient data could be used or monetized in the future.
Turbiner said that she doubts that federal immigration enforcement officials would actually comb through the claims data, but any gray area feeds the fears of some patients Zufall serves.
"We are concerned about the actual risk, but also the appearance of risk," Turbiner said.