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Guidance for understanding and communicating about the price of health care.
Transformation toward value-based healthcare is reshaping the delivery of care, patient expectations, and payment structures.
Improve your revenue cycle performance through standard metrics, peer comparison, and successful practices.
As Americans pay a greater proportion of their healthcare costs out of pocket, they have an urgent need for meaningful and transparent price information. HFMA convened a multi-organizational task force to reach a consensus about the best way to make accurate, relevant price information available to consumers. Although the task force focused its efforts on price information, task force members agreed that price transparency information should be paired with other value-related information, such as quality and safety, when available.
The task force's efforts culminated in HFMA's April 16 release of a report that offers guiding principles and recommendations for improving price transparency in health care.
"People everywhere want to be smart healthcare consumers, but information about healthcare prices is not easily accessible," says HFMA president and CEO Joseph J. Fifer, FHFMA, CPA, commenting on the report’s release. "For too long, it has been unclear how consumers should go about getting price information—who to ask, what to ask for, or what the information even means when they do receive it. This approach is a game changer."
The task force started by establishing common definitions, went on to develop basic principles to guide transparency efforts, and then used those principles to outline price transparency frameworks and recommendations tailored to the needs of various care purchasers.
Key terms related to healthcare prices can be ambiguous. Patients and insurers view the cost of health care from very different perspectives, for example. Recognizing the fundamental importance of a shared vocabulary, the task force makes clear distinctions among charges, prices, and costs, as as well as among other definitions of various healthcare stakeholders and stakeholder interests.
The concept of price transparency itself has been subject to a variety of interpretations. Prioritizing transparency for care purchasers, the HFMA task force defines transparency as readily available information on the price of healthcare services that—together with other information—helps define the value of those services and enables patients and other care purchasers to identify, compare, and choose providers that offer the desired level of value.
The task force believes efforts to achieve price transparency should be guided by the following principles:
These guiding principles inform the task force's recommendations for price transparency frameworks.
Because care purchasers' information needs and sources vary, the task force recommends different price transparency frameworks for different care purchaser groups.
Insured patients. Health plans should serve as the principal source of price information for their members. Along with other suppliers of price information, health plans should introduce different frameworks for communicating price information to insured patients and should be innovative in their approaches.
Transparency tools for insured patients should include some essential elements of price information, including:
Also, patients should be alerted to the need to seek price information from out-of-network providers.
To ensure valid comparisons of provider price information, health plans and other suppliers of such information should make transparent the specific services that are included in the price estimate.
The task force further recommends that government agencies should develop similar transparency frameworks for beneficiaries of public programs such as Medicare and Medicaid.
Uninsured and out-of-network patients. The task force agrees that providers should be the principal source of price information for uninsured patients and patients who are seeking care from the provider on an out-of-network basis.
Price transparency frameworks for uninsured and out-of-network patients should reflect the following basic considerations:
Employers. Fully insured employers should continue to use and expand transparency tools that assist their employees in identifying higher-value providers.
Self-funded employers and third-party administrators should work to identify data that will help them shape benefit design, understand their healthcare spending, and provide transparency tools to employees.
Referring clinicians. Referring clinicians should help a patient make informed decisions about treatment plans that best fit the patient’s individual situation. They also should recognize the needs of price-sensitive patients, seeking to identify providers that offer the best price at the patient’s desired level of quality.
Although price information resources are becoming more widely available, patients may not know where to find them. In conjunction with this price transparency report, HFMA has developed a guide to help patients know where and how to get information about healthcare prices. The resource, Understanding Healthcare Prices: A Consumer Guide, is designed to be distributed by providers, payers, employers, and other organizations with an interest in helping people navigate the healthcare system.
The task force recognizes that other aspects of price transparency will require monitoring and, potentially, policy solutions. These aspects include the impact of transparency on price negotiations within the business-to-business marketplace between health plans and providers and on providers' ability to provide societal benefits such as services (e.g., a Level I trauma center) or programs (e.g., a strong teaching and research mission) that may not produce a profit or positive margin or service to low-income, indigent, or rural populations.
In conclusion, implementing the task force’s recommendations will go a long way toward improving price transparency for care purchasers. But these recommendations are only a starting point. It is incumbent upon all industry stakeholders to act on the task force’s recommendations in a concerted effort to provide the price information that will give patients the ability to make informed care decisions.
Sidebar 1HFMA Price Transparency Task Force: Participating Organizations
Charge. The dollar amount a provider sets for services rendered before negotiating any discounts. The charge can be different from the amount paid.
Cost. The definition of cost varies by the party incurring the expense:
Price. The total amount a provider expects to be paid by payers and patients for healthcare services.
Because the definition of cost varies according to the party in question, the report minimizes the use of the term.
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.
Copyright 2016, Healthcare Financial Management Association.
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