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When federal- and state-run health insurance marketplaces (formerly known as exchanges) begin operating, many uninsured patients will gain health coverage—a big boon for the hospitals that serve them. But revenue cycle leaders must prepare for additional administrative tasks that will come with those patients newly eligible for health coverage. Deed McCollum, patient finance manager at Boston Medical Center (BMC), learned that first hand when Massachusetts introduced its marketplace in 2007. Hospitals need to be prepared to educate newly insured patients about how to obtain and maintain insurance coverage, she says.“Many of these patients never had health insurance, so purchasing insurance was an entirely new concept. They didn’t know they had to select a health plan and pay premiums, and they didn’t pay attention to the letters with instructions about determining their insurance eligibility,” she says. “These patients will come out of coverage again and again if you don’t educate them about the process and their responsibilities.”
The federal government defines a health insurance marketplace this way: “a state-based competitive marketplace where individuals and small businesses will be able to purchase affordable private health insurance.” Although each state will have its own health insurance marketplace, some marketplaces will be operated wholly or in part by the federal government, as detailed in a map developed by The Kaiser Family Foundation. According to current plans, marketplaces are supposed to start enrolling members on Oct. 1 of this year for coverage that can start on Jan. 1, 2014. The marketplaces will:
The insurance plans offered on the marketplaces will be bucketed into four categories:
Consumers will be able to access the marketplaces by telephone or via a website. Although one of the key objectives of the marketplaces is to make choosing and enrolling in health insurance easy, Richard Silveria, BMC’s senior vice president and CFO, says many lower-income patients may find it difficult to use the health insurance marketplace websites. “They either don’t have web access or they don’t do much web commerce, so it’s not always intuitive to them,” he says. The draft version of the application (Appendix D under the “Downloads: CMS-10440”) to purchase insurance is about 8 pages long, while the financial assistance application (Appendix C under the “Downloads: CMS-10440”) is approximately 21 pages long and includes terminology about insurance that may be challenging to patients who have never been insured before. In 2014, HHS expects to receive more than 4.3 million applications for financial assistance, according to an Associated Press report.The Centers for Medicare & Medicaid Services released two videos that demonstrate the web-based marketplace application process for an individual and for a family of three.
BMC is a safety-net hospital that has about 1 million outpatient encounters per year. When the Massachusetts Health Connector came online in 2007, BMC nearly doubled its financial counseling staff from 11 staff members to 21.The financial counselors went through training provided by the Connector as well as BMC’s own health insurance marketplace training curriculum. A script was developed to help financial counselors interact with patients efficiently. Financial counselors were also coached on how to find answers to patients’ questions. With the goal of getting coverage for as many patients as possible, BMC placed financial counselors in areas around the campus where they had not traditionally had a presence. “Many self-pay patients were used to coming to the emergency department for healthcare services, so we wanted to make sure that we were converting them to insurance,” McCollum says. “We had to make ourselves available throughout the hospital campus.” All uninsured patients at BMC were referred to a financial counselor, who generally spent 30 minutes or more educating them about their insurance options and helping them to apply. As an increasing number of patients gained coverage and learned to handle the responsibilities that come with insurance, the need for the additional counselors lessened. After about two years, BMC started reducing the size of its financial counseling staff through attrition. Today, the medical center employs 11 counselors, the same number it had before the health insurance marketplace was established.
In Massachusetts, hospital financial counselors also play a big role in educating patients about how to keep their coverage and how to use the healthcare system wisely. “Hospitals—or any other site where patients receive care—do that best because they have a vested interest in keeping patients in coverage,” McCollum says. Among other things, patients must be educated about:
It is important to educate patients during hospital or outpatient visits because it can be difficult to reach them after they leave, says Silveria. It is anticipated that many of the new enrollees will have low incomes, which may mean they do not have telephone or email access. In addition, some may not realize they need to notify their insurance carriers and healthcare providers if they change addresses.“When you have the patients in front of you, try to get everything done because you don’t know whether you will have another opportunity,” says Silveria.
As a group, the patients who gain insurance through a health insurance marketplace will be different than those who currently have coverage, according to an analysis by PwC Health Research Institute (Health Insurance Exchanges: Long on Options, Short on Time, PwC Health Research Institute, 2012.) The Congressional Budget Office estimates that about 12 million Americans will purchase insurance through a health insurance marketplace in 2014, and that number will more than double by 2021. The PwC analysis reports the following common characteristics of people who will enroll in individual coverage via a health insurance marketplace:
In BMC’s experience, health insurance marketplace enrollees do not all flock to the lowest-premium insurance option, but many of them do buy a plan that comes with high deductibles and copayments relative to their disposable income.“The out-of-pocket costs are a challenge to folks,” Silveria says. “As you put more out-of-pocket costs on people who are at the lower end of the pay scale, they have to make some decisions on what bills they pay, and that just puts more credit risk on providers.”
Silveria identifies several steps that revenue cycle leaders can take to prepare for the health insurance marketplace era:
“With self-pay patients, you don’t have to get authorizations and referrals, but when these patients are enrolled, you have the downstream work of making sure those are in place,” he says. “Now you actually have to submit a claim to a payer and then follow up versus maybe writing it off under the charity care policy right away. And now you need staff to handle the patient billing.”
Lola Butcher is a freelance writer and editor based in Missouri. Quoted in this article (in order of appearance):Deed McCollum is patient finance manager at Boston Medical Center, Boston (email@example.com).Richard W. Silveria is senior vice president and CFO, Boston Medical Center, Boston (Richard.Silveria@bmc.org).
Publication Date: Wednesday, March 20, 2013
TriMedx helps health systems control costs and uncover savings opportunities by optimizing the clinical engineering function.
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.
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.
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.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
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.
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 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.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
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.
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.
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.
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.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
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.
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.
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 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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