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Transformation toward value-based healthcare is reshaping the delivery of care, patient expectations, and payment structures.
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As the call for price transparency in health care intensified earlier this year, John Muir Health, a two-hospital system in California, found itself in the local newspaper. A columnist was trying to help an 85-year-old woman understand why the bill for her emergency department visit topped $11,500. Of course, that amount reflected the health system’s chargemaster prices, not the amount that the patient owed or necessarily the amount the insurer paid. “At the end of the day, that patient had $0 out-of-pocket responsibility for that bill, but she didn’t understand how it worked,” says Chris Pass, senior vice president of revenue cycle and analytics, John Muir Health in Walnut Creek, Calif. “To make headway on this common problem, we need to make the billing process simpler.” Like all health systems, John Muir Health faces daunting barriers, many of which are imposed by payers and regulations, to providing true price transparency for its patients. Its executives have chosen to focus on one aspect of price transparency—the patient’s out-of-pocket responsibility—and they are carrying out a three-pronged strategy:
Leah Binder, CEO, The Leapfrog Group, says that transparency means one thing to patients. “The only thing that patients care about is how much the care is going to cost them,” she says. “They aren’t interested in what Medicare, their insurer, or their employer is paying the hospital or physician practice. Patients want to understand what they would have to pay for the best possible care. They would also like to know what they would pay for not-so-great care.” Creating a true marketplace in which patients make choices based on cost and quality will require upfront information about a patient’s out-of-pocket costs. “Patients want to know what they will be expected to pay for healthcare services before they incur the costs,” says Richard L. Gundling, HFMA’s vice president of healthcare financial practices. “Financial discussions that occur after services are delivered deprive patients of the ability to make informed choices about their treatment options.” Meanwhile, private insurers and self-insured employers want to know the total charges to both payers and patients. “There are many different purchasers of health care who may care very much about prices, and their concerns may be different than those of patients who are not paying directly for the majority of the cost of their care,” says Anders Gilberg, senior vice president of government affairs, Medical Group Management Association.
Until the framework is established, individual health systems are limited in their ability to provide true transparency. For one thing, hospital chargemaster prices are important to the private insurance system. “A lot of insurers give discounts off chargemaster prices to their customers,” Pass says. “So if we lowered our chargemaster prices to what we get paid, the perceived discount goes away. That really upsets their business model.” Meanwhile, regulations prohibit providers from some billing practices that might reduce patients’ confusion when they open their statements. For example, providers are not allowed to show only an insurer’s negotiated rate on a patient billing statement. For commercially insured patients, hospitals must show:
For Medicare patients, the bill must show the chargemaster price, the Medicare payment, and the amount the patient owes. John Muir Health is looking for opportunities to lower some of its chargemaster prices, which are based on competitors’ charges and the health system’s contract terms with various insurers. The analysis that is under way seeks to find if John Muir Health’s prices are higher than necessary for certain services, relative to the market, and whether the health system could lower those prices without losing any revenue. “We feel like there probably will be some pockets of charges that, because of contract changes, we could reduce some prices,” he says. “My past experience tells me that that won’t solve the issue of price transparency, but we may be able to close the gap between charges and payments somewhat.”
Pass thinks patients will be better served by John Muir Health’s work to improve its patient statements. That initiative began in 2011 when the system decided to acquire a new information system to support both clinical transformation and revenue cycle improvements. John Muir Health’s efforts to improve its bills include the following: Easier-to-read statements. “We are redesigning the look and feel of the statement, how it reads, and everything about it,” Pass says. Patient feedback is being used to make sure the new statements are easy to understand Consolidated statements. By next March, patients will receive a single statement that shows the charges of all hospitals, ancillary providers, and physicians (except independent physicians who are not contracted with John Muir Health) on a single document. Each individual service will be delineated, but a single overall charge, the insurer’s total payment, and the patient’s total responsibility will appear at the end. New billing protocols. After experimenting with various approaches, John Muir Health no longer sends patient statements until insurance claims have been paid. Previous attempts at communicating with patients before claims were paid resulted in confusion. For example, the health system tried sending patients a courtesy notice 60 days after a service was rendered that explained the insurance claim was still outstanding. “We got a lot of negative feedback from patients about this notice. They wondered, ‘Why are you even bothering sending me this?’ So now we wait until we get clarity around what patients truly owe before we send them a bill,” Pass says. Single point of contact. John Muir Health’s customer service unit has been reorganized so all representatives work together, but currently patients still have to call different numbers to discuss different bills. When the new information system launches next year, patients will be able to call a single number and speak to a single representative who can address questions about any component of a John Muir Health statement. Upfront estimates. John Muir Health is also planning to improve the kind of upfront transparency needed to support a true marketplace. To date, few patients in John Muir Health’s market seek out-of-pocket cost estimates before they seek healthcare services. But Pass is preparing for the day that such requests become commonplace. When the new software is in place, a new process for providing upfront out-of-pocket estimates will be established.
John Muir Health offers an opt-in automated telephone survey for patients who contact the health system with questions about their bills. The survey seeks feedback on patients’ experience with the bill payment process. The concerns and questions that patients provide are logged so staff can identify opportunities for improvement. If fewer patients express frustration in that survey—and in their comments to front-line staff—about their top issue, Pass will know that progress is being made. “The No. 1 concern that patients report is ‘I don’t understand my bill,’” he says.
Lola Butcher is a freelance writer and editor based in Missouri. Interviewed for this article:
Leah Binder is CEO, The Leapfrog Group, Washington, D.C. Anders M. Gilberg is senior vice president, government affairs, Medical Group Management Association, Washington, D.C. Richard L. Gundling is vice president, healthcare financial practices, HFMA, Washington, D.C. Chris Pass is senior vice president of revenue cycle and analytics, John Muir Health, Walnut Creek, Calif., and a member of HFMA's Northern California Chapter.
Publication Date: Wednesday, September 18, 2013
In this Business Profile, Shawn Yates, director of healthcare product management at Ontario Systems, discusses the growing challenge of managing self-pay accounts and provides insight on how providers can successfully collect patient payments.
In this business profile, Cathy Smith, leader of the revenue transformation consulting practice at The Claro Group discusses how the organization helps hospitals and medical groups reimagine their revenue cycle.
In this business profile, Deloitte & Touche LLP executives Anne Phelps, principal and U.S. healthcare regulatory leader, and Daniel Esquibel, senior manager, explain ways health systems, health plans, and physician practices can prepare for MACRA.
In this Business Profile, Bruce Haupt, president and CEO of ClearBalance, discusses how a patient loan program can increase patient collections, reduce bad debt, and speed cash flow.
In this Business Profile, Jerry Bruno, principal with Deloitte Consulting LLP, discusses the importance of choosing revenue cycle solutions that help an organization meet the challenges of a quickly evolving healthcare environment.
In this business profile, Lane Jackson, a partner in the Grant Thornton LLP Health Care Advisory Services practice, with extensive experience in overseeing system implementations and revenue cycle reorganizations, discusses best practices for elevating revenue cycle performance during an EMR implementation. Grant Thornton LLP is a sponsor of the Large System Controllers Council Affinity Group.
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.
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.
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.
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.
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.
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.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
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.
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
Drive down costs while improving quality in a reform environment.
Receive expert insights and how-to action to achieve and maintain peak revenue cycle performance.
Access expert insights on financial forecasting/planning, strategic partnerships, capital allocation, and more.
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