SAIL INTO REVENUE CYCLE SUCCESS

AAHAM ANI OCTOBER 16, 2014

O PER AT I O N A LI Z I N G N EW T R A N S PA R EN C Y R EQ UI R EM EN TS & EX PEC TAT I O N S :

THE NEW NORMAL

Katherine H. Murphy, FHAM, CHAM, VP Revenue Cycle Consulting, Passport-a part of Experian Lisa Tozier, CPC, Revenue Cycle Project Manager (formerly at St. Joseph Hospital, Bangor, Me.)

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

Can we make a complicated process simple?

Doc, What is

Healthcare

Transparency?

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

YOUR PRICE IS A SECRET!

TRENDING DISCUSSIONS IN HFMA’S REVENUE CYCLE FORUM

FROM THE CMS WEBSITE

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

9/22/2014 8

So…Lola,what did you say a “dial tone” was for?

POINT OF SERVICE BILL USED TO

ENTER CHARGES/ORDERS

& TO COLLECT 1983-1999

THE PATIENT BALANCE DEATH SPIRAL

9/22/2014 11

$200

2005 2007

$250

$250

$265

2015

$312

$420*

-- CONSUMER TO PAYER -- -- CONSUMER TO PAYER --

Breakdown of U.S. Healthcare Consumer Responsibility U.S.$ billions, estimates

-- CONSUMER TO PROVIDER --

-- CONSUMER TO PROVIDER --

$450

$515

PROJECTED $732

*Source: 2007 & 2009 McKinsey analysis

12

If only Price Transparency

was this easy!

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)

. • Office Visit…

• Scheduling…Testing…

• Admission/Reg…

• Discharge…

• Billing…for svc you provided

• Payment

• Bill me

• Connected to EMR’s/ACOs

• Confirm appt / Pt Arrival/ Results

• PreService Clearance prior

• Phys office + specialists + Others

• Billing=combination of providers

• Bundled Payments

• Pay me

Old Paradigm – episode of care

New Paradigm – Pop Health Mgmt

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

Moving from Volume to Value: What’s Different? Degree of Transparency!

16

SO IT SHOULDN’T BE A SURPRISE THAT…

• Notice to Patients Required for Outpatient Facility Fees • 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 non-

elective 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

• 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.

• Collect from those who don’t qualify

• Extend payment terms and fundraising options for larger

balances.

9/22/2014 26

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!

Providers must…

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

• 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

• 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

• 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 WE DO NOT COLLECT FROM THE FOLLOWING PEOPLE

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

CT, MRI, NUC, US, Sleep Lab, EEG $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

REMEMBER TO SMILE WHEN YOU SAY HOW WOULD YOU PREFER TO PAY FOR THAT TODAY

TACKLING PRICING TRANSPARENCY • 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

• Payment plan creation

• Portal payments + Prior Bal.

• Ability to explain calculations

OUCH!

#1 : SUPPORT FROM INTERNAL RESOURCES

• 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 pre-

processing

VENDOR SELECTION

vendor

43

vendor

Integration of Tools

Ease for End User

All-inclusive Products

Communication &

Customer Input

Customer Support

COB SMART – WOW!

INCLUDE/EXCLUDE? (OUT OF POCKET OPTIONS)

DRILLING DEEPER INTO PRICING

• 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

Combined Estimates

I’ll splaine 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 denial codes to rebill?

• How must administrative cost is there?

Benefit data

Contract Data

Cashiering Tools

Payment Estimate

HOW DO YOU MAKE THIS POSSIBLE?

Financial Triage &

PIV Accurate Data & Denial

Prevention

Transparency Gone Wild!

54

SOMETIMES TRANSPARENCY IS WELL…

• Disclaimer verbiage

• Communicate typical variances up front

• Additional amount due vs. refund

Opague

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

9/22/2014 55

GUESSTIMATRON MAGIC

TRANSPARENCY NAVIGATOR

ESTIMATRON CLIFF NOTES

WHY PATIENTS CANNOT EASILY DO ESTIMATES?

CONSUMER FACING ESTIMATES

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

WILDLY OPTIMIZING BEGINS AT THE VERY BEGINNING!

• 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.

OPTIMIZATION

END GOAL

63

Healthy Happy Consumers A healthy Provider revenue cycle

9/22/2014

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

9/22/2014 65 Passport Health a Part of Experian

BE USER FRIENDLY & INTUITIVE. SHOW HEALTHCARE CONSUMERS

THE LOVE!

9/22/2014 66

AAHAM

Meaningful use: More than 50 percent of all unique patients online access to

their health information (& many will pay online!)

Precisely I.D. your patients and enroll in your Patient Portal!

500,000 known, verified fraud records

KEEP IT SIMPLE

Abc123

AND EXPLAIN IT IN PATIENT TERMS

WITH THE GOAL OF TRANSPARENCY

Is to be

W-E-L-L

What Patients Want

EDUCATION / AAHAM / CERTIFICATION

• Ham & Egg Breakfast

• The Chicken is invested

• The Pig is committed!

• Achieving Success comes at a price

Congratulations and THANK YOU

for another G--R-E-A-T AAHAM ANI!

!TRANSPARENCY!

Katherine H. Murphy, FHAM, CHAM, VP Revenue Cycle Consulting, Passport-a part of Experian

Lisa Tozier, CPC, Revenue Cycle Project Manager (formerly at St. Joseph Hospital, Bangor, Me.)