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To decrease inappropriate emergency department (ED) use, Midland Memorial Hospital, serving Midland County, Texas, introduced a telephone triage system in 2009. The free service allows county residents access to medical advice from a registered nurse (RN) about whether a medical situation justifies an ED visit. Patients who arrive at the ED and do not need emergency care—often referred to as non-emergent patients—are given the option of seeking treatment in a less costly setting, such as the nearby urgent care center, or paying $150 before they are treated in the ED. By promoting suitable alternatives to ED use, Midland Memorial Hospital is successfully redirecting non-emergent patients to more appropriate care options and dramatically improving ED throughput. A bonus: The hospital’s bad debt fell by more than $3 million in the first year as a result of the initiative. Meanwhile, patients who need emergency treatment are being seen much more quickly, and those who do not are saving money. “We don’t collect a lot of those $150 copays or deposits for care in the ED,” says Midland Memorial CFO Stephen Bowerman. “People would prefer to be treated at the urgent care center at half the cost.”
Midland Memorial is one of many hospitals that are charging upfront fees to reduce ED crowding. Indeed, HFMA’s Richard L. Gundling, FHFMA, CMA, vice president of healthcare financial practices, says at least half of all hospitals are now charging up-front fees for non-emergent care and collecting deductibles and copayments at the time of service. Of the more than 6 million ED visits to HCA hospitals in 2011, about 314,000 were screened by a clinician and determined not to have an emergent condition. Advised of their options, about 80,000 chose to seek an alternative setting while about 233,000 remained in the ED for treatment and paid an up-front fee—typically between $100 and $150—to do so, says Ed Fishbough, a director for HCA. “It has been a successful part of helping to reduce crowding in emergency departments and to encourage appropriate use of scarce resources,” Fishbough says. “This helps ensure that the sickest patients get treated quickly and that those who do not have an emergency have access to more efficient, less costly care settings.”For HCA, up-front fees for non-emergent patients visiting the ED started in a Houston hospital in 2004. Although the practice has spread to other HCA facilities, fewer than half of its hospitals currently charge upfront fees. Of those that do, each hospital sets the fee. Pregnant women, children under age 5, and patients who are 65 and older are excluded from HCA’s up-front-fee policy. In addition, clinicians can decide to exclude non-emergent patients from the policy on a case-by-case basis. Typically, two caregivers—for example, a triage nurse and a physician—make a determination about whether to waive the upfront fee in a specific situation.
Up-front fees may have a potential downside, warn some experts: Uninsured patients who truly need emergency care may fear going to the ED because they worry that they will be asked to pay on arrival.Midland Memorial is avoiding that repercussion with its telephone triage system, which directs patients to the best place to seek care. The telephone nurse triage system allows individuals to discuss their symptoms with a registered nurse (RN), who advises them on the proper setting for treatment. The nurses use a proprietary software program, developed by a vendor. It prompts them to ask callers a series of questions about their symptoms and uses algorithms to help the nurses make one of five recommendations:
The phone line, staffed by RNs hired by Midland Memorial, operates around-the-clock 365 days a year. Typically, a single RN staffs the triage line. However, in the three years since it was implemented, Memorial Midland has identified certain time periods in which call volume is heavy, and a second nurse is added during those periods. Maintaining the telephone triage system costs about $500,000 a year, Bowerman says. That includes the salary and other staff costs as well as the software (i.e., the computerized protocols) that helps the nurses evaluate patients’ symptoms. In January 2012, Medical Center Hospital in Odessa, Texas, began partnering with Midland Memorial on the nurse triage line. The two hospitals now split the costs and are working to grow the triage line into a regional service.
In compliance with Emergency Medical Treatment and Active Labor Act, Midland Memorial does not discuss potential ED fees with patients until after they are examined. When patients present at the ED, they are screened for any emergency medical conditions by a physician. If a patient requires emergency care, treatment proceeds.If emergency treatment is not necessary, a member of the registration staff comes into the room to notify the patient about the physician’s determination and to gather insurance information. Patients who do not have insurance are asked to pay $150 before treatment continues or to seek treatment at another setting.These ED screening exams identify between 200 and 300 patients a month—about 5 percent to 7 percent of those who arrive at the ED—that would be more appropriately treated elsewhere. “We have access to the schedule of our urgent care center in town, so we can schedule patients there. It’s much cheaper than $150, and we can usually get patients in within 24 hours,” Bowerman says. “If they need assistance in making an appointment at the federally qualified health clinic, we will assist them with that.”
Midland Memorial’s introduction of upfront ED fees has been successful, Bowerman says, because the nurse hotline was introduced at the same time. The approach has contributed to improved performance on several important measures:
Bowerman credits the nurse hotline for Midland Memorial’s relatively smooth transition. “It was a dramatic change for people who felt they needed to come into the emergency department,” he says. “The telephone nurse triage was helpful because it gives people an avenue to seek before they show up in the emergency department and spend a couple hours going through the medical screening exam process—only to be classified as non-emergent.” Here are some other tips for success from Midland Memorial:Heavily market the nurse triage line. The half-million dollar cost of the nurse triage line is a fixed cost no matter how many calls are taken, Bowerman says, “So we want people to use that line.” In addition to radio ads and billboards, Midland Memorial sought publicity in the local media and advertised the service in its ED. Midland Memorial educated primary care physicians and the staff at the nearby federally qualified health clinic about the nurse hotline and asked them to encourage patients to use it. The hospital also sent refrigerator magnets to all residents in the mail and promoted the triage line with a flier in English and Spanish.
All the promotion has paid off. Within the first year, call volume for the nurse hotline grew by about 1,500 calls—from an average of 2,000 to 2,500 calls per month to between 3,500 and 4,000 calls. Seek early support from ED physicians. Before introducing the ED medical screen exam and up-front fees, gain buy-in from ED staff on funneling patients to the proper care settings. At Midland Memorial, an independent company employs and manages the ED physician staff. “We probably would not have done this had we not had their support from the beginning and their participation as we developed the process,” Bowerman says. Lawrence Wilson, MD, the hospital’s medical director of emergency medicine and hospitalist services, says implementing the upfront collection policy had minimal impact on the emergency physicians other than the requirement of performing medical screening exams so that non-emergent patients can be referred to other sites of care. Although the policy does speed ED throughput for patients who need emergency treatment, ED volume continues to increase, and some patients continue to rely on the ED for primary care. “Importantly, we are helping make our patient population aware of the alternative routes to primary care,” Wilson says. “Nevertheless, when the availability of primary care is a challenge for many of our patients, we are still serving the role of safety net.”The biggest beneficiaries of Midland Memorial’s approach are patients who need emergency care. “The patients who have emergent needs certainly appreciate this new program because they know our emergency department physicians’ attentions aren’t diverted by other cases that don’t require immediate care,” Bowerman says.
Lola Butcher is a freelance writer and editor based in Missouri. Quoted in this article (in order of appearance):
Stephen Bowerman, CFO, Midland Memorial Hospital, Midland, Texas, is a member of HFMA’s Lone Star Chapter (email@example.com).Richard L. Gundling, FHFMA, CMA, vice president of healthcare financial practices, HFMA, Washington D.C. (firstname.lastname@example.org).Ed Fishbough, a director, HCA, Nashville, Tenn. (Ed.Fishbough@HCAHealthcare.com).Lawrence Wilson, MD, medical director of emergency medicine and hospitalist services, Midland Memorial Hospital, Midland, Texas.
Publication Date: Wednesday, January 23, 2013
A leader from McKesson discusses how healthcare reform is forcing hospitals and health systems to take a different approach to capacity management and patient flow.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Jim Bohnsack, vice president, solution & corporate development for Conifer Health Solutions, explains how the company helps healthcare providers leverage data to deliver better outcomes while optimizing reimbursement for all payment arrangements.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Elena White, vice president of risk, quality, and network solutions for Optum, discusses how healthcare providers can leverage data and technology as they enable risk in their organization.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Somnia President and CEO Marc Koch, MD, MBA, explains how hospitals can drive transformative change in the perioperative experience for outstanding clinical and financial outcomes.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
PMMC President Roger L. Shaul discusses the effects of healthcare reform on revenue cycle management and how PMMC's products help clients adapt to a changing financial environment.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
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