Transcript Presentation Title

Educational Conference & Exhibition
Patient Access:
The First Connection to a Lasting Impression
September 23, 2014
Operationalizing New Transparency Requirements
Katherine H. Murphy, FHAM, CHAM
VP Revenue Cycle Consulting, Passport/Experian Health
WHAT PATIENTS WANT
• Designing Access is the Most Important Initiative
You Can Undertake
• Expertise from Y-O-U!
• They do not want to work hard for Access or
Information
(“If you make me work hard to do business with you I
will go somewhere else”)
They want to be
W-E-L-L
Paul Roemer, VP Clinovations/Pale Rhino Consulting
TRANSPARENCY - DEFINED
• Generally implies openness, communication, and
accountability. Transparency is operating in such a
way that it is easy for others to see what actions are
performed.
• “The perceived quality of intentionally shared
information from a sender".
• Infusion of greater disclosure, clarity, and accuracy
into their communications with stakeholders
Can we make a complicated process simple?
Doc, What is
Healthcare
Transparency?
TODAY’S LESSON
• Transparency Overviews
• Best Practice
• Industry Best Practice recommendations
• How to follow the recommendation
• Provider Journey
• Provider success story: The start up & current
state
• Transparency future state
• Transparency Gone Wild! (Going the Extra Mile)
• Technology
• Patient Engagement
• How to drill down estimates and be closer to the
truth!
THE WAY WE WERE
So…Lola,what
did you say a
“dial tone”
was for?
7/22/2015
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THE PATIENT BALANCE DEATH SPIRAL
PROJECTED
$732
Breakdown of U.S. Healthcare Consumer Responsibility
U.S.$ billions, estimates
$420*
$515
$450
-- CONSUMER TO
PROVIDER --
$265
-- CONSUMER TO
PROVIDER --
$250
$200
-- CONSUMER TO PAYER --
2007
2005
*Source: 2007 & 2009 McKinsey analysis
7/22/2015
$250
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-- CONSUMER TO PAYER --
$312
2015
If only Price Transparency
was this easy!
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I know everyone will be excited about new ways not to get paid
TRANSPARENCY CAN OCCUR WHENEVER THERE IS
COMMUNICATION BETWEEN ANY TWO OF:
-
Insurer
Provider: hospital/physician/Patient Access & Patient
Primary Care Physician
Specialist
Ancillary testing facility
Post Acute Care
- Nursing Home
- Home Health
- Family Caregiver
- Pharmacy
TODAY TRANSPARENCY ACROSS THE CONTINUUM!
(NOT RELATED TO ANY ONE EPISODE)
Old Paradigm – episode of care
. • Office Visit…
New Paradigm – Pop Health Mgmt
• Connected to EMR’s/ACOs
• Scheduling…Testing…
• Confirm appt / Pt Arrival/ Results
• Admission/Reg…
• PreService Clearance prior
• Discharge…
• Phys office + specialists + Others
• Billing…for svc you provided • Billing=combination of providers
• Payment
• Bundled Payments
• Bill me
• Pay me
Moving from Volume to Value: What’s Different?
Degree of Transparency!
From
To
Fee for Service
Payment
Risk and/or Incentives for Keeping Patients
Healthy. P4P (Pay for Performance),
Shared Savings, Capitation
Care Not Coordinated
Between Providers
Providers Managing Continuum of Care.
Right Care at the Right Place/Time. Care
Coordination, Transitions of Care
leveraging community resources
No Shared Patient
Information
Electronic Health Records enable
information Sharing. Health Information
Exchange
Doctors Wait for Sick
People to Show Up
Predictive modeling, Proactive Monitoring
and Outreach. Telemedicine, Patient
Centered Medical Home, Home visits
Patients Wait for
Providers to Tell Them
What to Do
Patients Actively Engaged in Improving
and Managing their Health. Personal
Health Records, Home Monitoring Devices,
Patient Engagement/Liability estimates
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SO IT SHOULDN’T BE A SURPRISE THAT…
• Notice to Patients Required for Outpatient Facility Fees
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Posted: 24 Apr 2014 11:36 AM PDT (Effective Oct. 2014)
The Connecticut House of Representatives responded on Wednesday to medical billing concerns patients
expressed over undisclosed and unexpected facility fees by unanimously passing a bill that requires notice.
Many patients expressed that the additional charges were a surprise when they received their bill. The
legislation now moves to the state Senate for a vote.
The charges, often referred to as "facility fees" are charged to patients by medical offices that are owned by
hospitals for outpatient care. These fees are separate from doctor fees. Facility fees range from several
hundred to thousands of dollars.
The bill to require notice to patients about fees possible extra charges for outpatient care at medical offices
owned by hospitals. The bill specifically requires that patients with scheduled appointments at medical
offices where facility fees are charged receive notice about the fees in plain language before they receive
treatments scheduled so long as the appointment is scheduled at least 10 days in advance. If the exact
nature of the services or insurance coverage is unknown the patients would be provided with an estimate
based on typical charges at the facility. Notice for patients receiving emergency care would need to be
delivered as soon as practicable after the patient is stabilized. The bill does not impact the offices' ability to
charge facility fees.
Other provisions in the bill are include requirements that the office prominently displays that the facility is
connected to a hospital, what hospital the office is affiliated with, and states that the patient may incur
higher charges than if they were treated at a facility that isn't hospital-based.
MASSACHUSETTS CHAPTER 224
The law aims to control health care cost growth through a
number of mechanisms, including the creation of new
commissions and agencies to monitor and enforce the health
care cost growth benchmark, wide adoption of alternative
payment methodologies, increased price transparency,
investments in wellness and prevention, an expanded primary
care workforce, a focus on health resource planning, and
further support for health information technology
NEW BUSINESSES
INVESTORS ARE DRAWN TO THE CONCEPT OF PRICE TRANSPARENCY, WITH
SHARES RISING 139 PERCENT ON ITS FIRST DAY OF TRADING.
• Castlight is helping patients select the best price,
and quality service. Are you ready?
• If you’re not offering competitive prices and high
quality outcomes employers and patients may start
taking their business elsewhere. Wall Street appears
to have casted their vote in favor of patient
consumerism.
CANARY – INFECTION TRANSPARENCY
“Using the breath biomarker, we can pick up the
body getting ready to fight infection ... even before
the patient is showing signs,”
SHAREPRACTICE - NEW WAY TO
RATE TREATMENT?
Yelp for Doctors? over 5,000 health care providers using
the app
TAPCLOUD
WHAT ARE WE TASKED WITH?
AND HOW DO WE ACCOMPLISH
ENTERPRISE TRANSPARENCY:
PROVISION OF CARE
• Provider organizations will have clear policies on how
to interact with patients with prior balances choosing to
have elective or non-elective procedures. They will
also have clear definitions for elective and nonelective procedures. These policies will be made
available to the public.
• Brochures, Website, all documents
• Patients do not speak ABN, MSP, elective, In from Out!
• Lasix vs Furosemide
BEST PRACTICES FOR TRANSPARENCY
• Have defined processes for all patient types:
EMR – OPT – INPT – Pre
• Discussion with Participants - not to disrupt workflow
• Patient Share Responsibility / Estimate / Navigation
Counselor
• When: Pre/Post Service, Emtala, Walk-ins
• Include Financial Screening along with Estimation
* Use of consumer data
* Toll Free number / Business Cards
• Appropriate Discussion Settings & Script
• Pre – Point - change in discharge process (fast pass?)
THE BEST PAYMENT PROMISE
Providers must…
• Know who is in front of them. I.D. your patient – Keep patient
SAFE & STOP RETURN Mail
• Define the medical language in CONSUMER language
• Have the correct insurance and benefit information.
• Tell patients what they will owe at the time of service.
• Enroll for Financial Assistance before rendering service.
• Extend hospital charity to those who qualify.
• Securely accept payment upfront for smaller balances.
• Extend payment terms and fundraising options for larger
balances.
Every patient leaves knowing what they owe & how their
services will be paid for!
Excellence in Patient Financial Triage includes determining
the Patient’s Preferred method for future Communications!
7/22/2015
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WHO, WHERE, WHEN?
HOW EASY IS THIS FOR YOU?
• Prior Balance Discussion
• Balances across their continuum of care
• Payment plans tailored to successful collection
• Summary of Care Document
• Annual Training of Registration – MSP,
Collections, Payer Skills, Industry trends &
updates
MEASUREMENT/COMMUNICATION
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Collections / accuracy
Consumer satisfaction Surveys / real time
Host Focus Groups
Define Medical and Legal terms and provide
access to them – See handout
• Access success – Reduction in Dups, return mail &
patient complaints, cancellations, no-shows
• Increase – patient satisfaction scores, collections,
employee satisfaction, positive internal relationships
•
• Display Confidence!
• Be sensitive to the situation (emotional intelligence)
• Be aware of cultural differences
• Be humane, respectful and honest
• Determine what leverage you have
• Be realistic – understand the strategy and policy
• Hire with these traits in mind
LISA TOZIER – ST JOSEPH’S STORY
PROVIDER OVERVIEW
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Faith Based organization
Bangor Maine, Population 33,000
St Joseph Hospital/Covenant Health System
Licensed for 112 beds
Self pay portions increased volume
Transparency & collection = new concept to patients
Delicacy in rolling out the changes and keeping within
the mission
PATIENT ACCESS/REVENUE INTEGRITY MANAGER
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Manage the day to day operations for a Patient Access staff of 30
Responsible for pre-reg, pre-cert, face to face reg and the ED
Manage the day to day operations for a Reimbursement staff of 3
Responsible for managing charging throughout the hospital
Responsible for managing RAC, MIC, ADR and 3rd party audits
Liaison between the revenue cycle departments
Lead our Revenue Integrity Team
Spend 2 hours a week working with Patient Accounts solving issues
Spend 2 hours a week working with IS to ensure our revenue cycle
computer systems are running correctly.
Lead implementation coordinator for all revenue cycle software
Maintain security for revenue cycle software programs
Responsible for the overall maintenance of the hospital’s
chargemaster
Responsible for the expanded proration file
BENEFITS OFFERED
• Patient discounts from Providers
• Financial Counseling Services
• Card give to patient for Counseling hours
• Establishing a Physical Space and staffing in
the ED (certified counselor for HIX)
Key Factor: Physical Space
CENTRALIZED & DECENTRALIZED
OVERSIGHT
• Challenges
• Training staff – 2 day with pre-reg staff and
time with education trainers
• ipad swipes / kiosks (where, which patients)
• Outcome: More Transparency = shorter
throughput
COMMUNICATION - LIAISON
• Role connectivity between rev cycle, ancillary and I.T.
departments to make process improvements
• Automated process developed allows for Patient
Access + PFS transparency.
• Dedicated price estimation line and dedicated
Financial Counseling line.
• Keep it Simple - allow for Patient Engagement via
patient portal, smartphones etc
Patient Responsibility Deposit Matrix
Department
SJH employees and their family with Aetna
through the hospital
Patient % Liability
with
Insurance or deductible from Passport or use
amount below
Medicare Patients with no secondary
Self Pay
Inpatient
$150 (if admitted through ED there is no charge)
$150.00
NONE
$500.00
MEDICARE PT WITH SECONDARY INS; ALSO, WHEN
MEDICARE IS THE SECONDARY INSURANCE
Emergency Department
$150 copay If they don’t have encourage payroll
deduction
$50.00 or copay per passport/card
$10.00
$200.00
PATIENTS WITH TWO OR MORE INSURANCES
Diabetes
$10.00
$10.00
$10.00
$100.00
MAINECARE PATIENTS WITH THE EXCEPTION OF THOSE
THAT HAVE A CO-PAY
Nutrition
$5.00
$5.00
$30.00 unless PT has dx of diabetes or renal
disease then nothing
$30.00
VA PATIENTS
Cardiology
$10.00
$10.00
$10.00
$90.00
WORKER'S COMP PATIENTS
Cardiac Cath
$50.00
$50.00
$50.00
$500.00
THIRD PARY LIABILITIES
ENDO (excludes colonscopies)
$50.00
$50.00
$50.00
$500.00
MVA'S
Outpatient Surgery
$50.00
$50.00
$50.00
$500.00
SCREENING MAMMOGRAMS
Pain Clinic
$50.00
$50.00
$50.00
$500.00
COLONOSCOPY PATIENTS
RBCC Diagnositics
$25.00
$25.00
$10.00
$200.00
RBCC Bone density
$10.00
$10.00
$10.00
$70.00
X-RAY
$15.00
$15.00
$10.00
$150.00
$20.00
$20.00
$10.00
$200.00
Wound Clinic
$20.00
$20.00
$10.00
$100.00
Infusion Clinic
$5.00
$5.00
$10.00
$50.00
Hyperbaric
$20.00
$20.00
$50.00
$250.00
CT, MRI, NUC, US,
Sleep Lab, EEG
REMEMBER TO SMILE WHEN YOU SAY HOW WOULD YOU PREFER TO PAY FOR THAT TODAY
WE DO NOT COLLECT FROM THE FOLLOWING PEOPLE
TACKLING PRICING TRANSPARENCY
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CDM
Historical Claims Data
Complex Contract terms
Manipulating pricing/co-morbidities
Correct Insurance plan codes
Rich Eligibility Data(Web, COB, HIX)
Carve outs
Ability to Pay
Propensity to pay
Collection process
OUCH!
Payment plan creation
Portal payments
Ability to explain calculations
#1 : SUPPORT FROM INTERNAL RESOURCES
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ED and ancillary staff
Revenue Cycle Departments
Senior Management – on board
I.T.!
Working to budget much needed resources
Provider owner physician practices & entities
All staff physicians
Their Office staff
Marketing
Educating consumers and supporting the vision
is everyone’s job.
QUALITY MANAGEMENT – IT’S WHAT’S
UPFRONT THAT COUNTS!
• Without quality data you cannot be transparent with
any sense of accuracy
• Scrub accounts upfront
• Auto scripting corrections means less rekeying and
less chance for error.
• Snapshots of electronic trx and info kept for audit
trail
• Reports! Communicate Success!
Ya Gotta Be a Team Player
GOALS FOR TRANSPARENCY IMPLEMENTATION
• ONE Integrated platform – Touchless processing! Lisa joined Exp/PP
• Work queues
• Address verification USPS and Validation
• Q.A.
• Eligibility Verification
• Scripting address & eligibility corrections/carrier codes
• Medical Necessity
• Automated Pre-Authorizations
• Patient Liability Estimator
• Payment Processing
• Patient Portal & results tracking/reporting
• Patient Kiosks & m devices (Pt check-in to streamline experience)
2015 – Financial Screening, Automated Charity apps
• Automated Physician Orders – legible/screened/ kick off!
• PreClaim scrubber and new claims processing solution
• New statements to better communicate bill, programs, even coupons!
FUTURE STATE
• Kiosks in all areas
• Scrubbing tool integrated with PFS
• Patient Portal for test results/appts and financial and
clinical communications
• Automated PreAuth
• Work closely with Provider owned practices to
move processes even farther to the front of the
patient experience
• Physician liaison role to assist with the physician
office relationships
• Automated phone calls to encourage preprocessing
VENDOR SELECTION
Customer Support
All-inclusive
Products
Integration of
Tools
Ease for End
User
vendor
Communication &
vendor
Customer Input
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COB SMART – WOW!
INCLUDE/EXCLUDE?
(OUT OF POCKET OPTIONS)
DRILLING DEEPER INTO PRICING
Combined Estimates
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Use Historical Claims Data
Use CPT & ICD codes
Cross walk CPT to ICD
Combine Hospital & Physician liabilities
Consider specific physician and location
Establish high, average, low pricing
Adjust specific line items
Access readiness for ICD10 in automated tool
I’ll splane our
silver burger plan
ELIGIBILITY HIX RESPONSE
HOW CAN YOU DENY ME TODAY?
• Grace Period = claim denied? Claim paid?
• Collect from patient & refund later?
• If the deductible hasn’t been met can’t you collect payment
anyway? It is not covered right?
• If the patient pays the premium…does this payment
automatically trigger a payment to the hospital?
• Will the hospital have to track and monitor denials to rebill?
• How must administrative cost is there?
HOW DO YOU MAKE THIS
POSSIBLE?
Benefit data
Contract
Data
Accurate
Data &
Denial
Prevention
Payment
Estimate
Financial
Triage &
PIV
Cashiering
Tools
Transparency Gone Wild!
SOMETIMES TRANSPARENCY IS WELL…
Opague
• Disclaimer verbiage
• Communicate typical variances up front
• Additional amount due vs. refund
50
WHY ESTIMATES HAVE TRANSPARENCY LIMITATIONS
• The user selected the wrong procedure
• The wrong insurance code was selected and not fixed
before the estimate was run
• A procedure was added on after the estimate
• Not all of the same surgeries will be the same
• Dealing with the unknown
• Co-morbidities…..
• Chargemaster updates
• Contract updates
• Benefits not always there
• Co-insurance-moving target
7/22/2015
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GUESSTIMATRON MAGIC
TRANSPARENCY
NAVIGATOR
ESTIMATRON CLIFF NOTES
WHY PATIENTS CANNOT EASILY DO
ESTIMATES?
CONSUMER FACING ESTIMATES
WILDLY OPTIMIZING BEGINS AT THE
VERY BEGINNING!
Key Components: (A-U-T-O-M-A-T-I-O-N)
• 1. Screen: who should not be targeted for
collections. Screen for bankruptcy, deceased,
Medicaid & Commercial eligibility and charity
eligibility.
• 2. Segment: to prioritize inventory and produce
optimal collection and treatment strategies.
• 3. Route: assign accounts to the most appropriate
role pre/post
OPTIMIZATION
• 4. Performance Management: Real-time
dashboards and to support and drive business
decisions.
• 5. Collaboration, Consultation and Analytics:
identify best practice collection strategies on going,
evaluate reports for opportunities and anoint
someone to oversee & champion process.
END GOAL
Healthy Happy Consumers
7/22/2015
A healthy Provider revenue cycle
59
WHAT OTHER KINDS OF WILD?
• Telemedicine
• Gamification applied to healthcare engagement (Let’s play a game…)
• Change your process to meet the needs for customers of all ages and
tech savviness.
• Hospitals compete for patients by developing their expertise in niche
markets. This could just be quality customer service, consumer
friendly processes, and confidence in experiencing the latest
technology in place right at the start.
• Servant Leader Management Style
TRY NEW THINGS! COLLABORATE WITH YOUR
BUSINESS PARTNERS TO MANAGE THE NEW MODELS
7/22/2015
Passport Health a Part of Experian
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BE USER FRIENDLY & INTUITIVE.
SHOW HEALTHCARE CONSUMERS
THE LOVE!
CHAM
500,000 known, verified fraud records
7/22/2015
Meaningful use: More than 50 percent of all unique patients
online access to their health information.
Precisely I.D. your patients and enroll in your Patient Portal!
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EDUCATION / NAHAM/AFFILIATES
• Ham & Egg Breakfast
• The Chicken is invested
• The Pig is committed!
• Achieving Success comes at a price
PATIENT ACCESS
Congratulations and THANK YOU
for another G--R-E-A-T CAHAM conference!
Katherine H. Murphy, FHAM, CHAM, VP Revenue Cycle Consulting, Passport-a part of Experian