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Although some health systems are taking a wait-and-see approach to the advent of state health insurance marketplaces, Trinity Health’s Preston Gee thinks proactive—even aggressive—preparations are appropriate. Trinity Health, based in Livonia, Mich., recently combined with Catholic Health East to form the second largest not-for-profit health system in the nation. The new organization has more than 87,000 employees, 82 hospitals and 89 continuing care facilities, with revenues of approximately $13.3 billion, and facilities in 21 states. Helping the new state health insurance marketplaces (formerly known as exchanges) accomplish the goal of expanding health coverage aligns with Trinity’s mission. “We were very active in terms of lobbying for the Affordable Care Act because it’s one of our core beliefs that everybody should have access to care, and the insurance route is certainly better than having to rely on the emergency room,” says Gee, who is senior vice president of strategic planning and marketing at Trinity Health.
On top of that, Trinity executives believe state marketplaces, which are supposed to start marketing Oct. 1 for coverage that begins Jan. 1, will be a tipping point in the way health coverage is purchased. Gee thinks health systems must organize themselves to succeed financially in a consumer-oriented retail environment in which many—and eventually most—people choose their coverage and shoulder an increasing amount of financial responsibility to pay for it. “This is where things are heading so providers need to be able to operate in this space,” he says. “To say, ‘We’re not going to wade into those waters,’ is somewhat precarious because I think this marks a significant shift.”
In the new environment, consumers rather than employers will be making decisions, and consumers will focus on cost and quality from an individual perspective, which is very different from that of an employer, which needs to balance the needs of an entire workforce. “There are huge implications on several levels, and for us, ‘winning’ means successfully transitioning into that new wave of consumer/patient interaction and retail orientation,” he says.Trinity Health’s goal is to encourage and facilitate consumer enrollment in the exchanges and to be a major player in the state insurance exchanges in each of its markets. Gee identifies several keys to success for health systems:• Establish good relationships and alignment with marketplace-oriented payers• Develop the ability to provide consumer assistance and educational efforts• Ensure consumer preference for the health system• Confirm capacity to handle increased volume, especially at the primary care level• Be transparent about quality and costs • Ensure ease of navigating the health system, both virtually and in real life• Develop a retail mindset among health system leadersTrinity Health started its preparations more than two years ago when leaders helped educate state leaders about the decisions they faced as they developed state exchanges. The early work also involved studying how the introduction of the Massachusetts Health Connector exchange influenced the health insurance and health delivery markets in that state. That review convinced Gee and his colleagues that the state exchanges present an opportunity not only to reduce uncompensated care and gain market share, but also to get a jumpstart on the future of healthcare purchasing and delivery. Gee and his colleagues educated Trinity Health’s senior leaders about the magnitude of the situation—Gee calls it a sea change— and started communicating about the importance of preparing for the state marketplaces throughout the organization.Trinity Health went on to develop a predictive model to understand how the exchanges are likely to affect the health system’s patient volume and finances. Trinity also created an organizational structure to develop and implement its health insurance marketplace strategy, assigned accountability at each hospital, and developed work plans and accountability milestones to stay on track with its goals.
Trinity Health’s review of Massachusetts’ experience included this finding: A health insurance marketplace serves as a “store” for health plans and health plans become the “store” for health systems. “So, from our standpoint, it is very important to have alignment with the right plans—and not necessarily just one plan because there are going to be multiple plans in each market,” Gee says.The goal is to identify the payers that are most likely to succeed in the health insurance marketplace in each of the 10 states in which Trinity Health operates and to be ready to offer the low-cost, high-quality care that makes those payers want to partner with Trinity Health.Gee and his colleagues evaluated payers in each Trinity Health market and prioritized them on several factors: One is the historical rapport between Trinity and the payer. Second is the payer’s understanding of the insurance exchange market: Gee wants health plans that recognize that exchanges represent a seismic shift in the insurance industry as opposed to viewing the exchange as a way for a few uninsured people to get coverage.A third key factor is the payer’s preparations to date. “The key thing for us is ‘How seriously are they taking this effort?’” he says. “What kind of resources are they committing to it? How astute are their financial folks and their actuarial people in terms of really understanding this market?”Through conversations with leaders at each plan, Trinity Health identified the payers that are most enthusiastic about succeeding in the state insurance market. “It is important to first determine who is going to be a player in the first round of the exchanges,” Gee says. “Secondly, who is going to be a viable player in terms of pricing appropriately? Because we learned from Massachusetts that pricing is very significant.”After identifying the payers that the health system wants to partner with, Trinity Health started discussing how they can work effectively together. In addition to the financial aspect of their relationship, payers and providers need to share goals for capturing market share and delivering high-value care that insurance marketplace shoppers will demand.“We want to approach this in tandem so that both of us are well-positioned and we have a good understanding of how to approach this new group of individuals who will be coming into the insurance market,” Gee says.
Meanwhile, Trinity Health is also making plans to engage in consumer education that will be necessary to make the health insurance marketplaces a success.A provision of the ACA requires each state insurance marketplace to provide “navigators” who help consumers understand their options and enroll for coverage. These navigators will work differently in different states; for example, some exchanges will contract with organizations to provide a certain number of navigators while other exchanges might employ navigators directly.Trinity Health wants to see all eligible consumers gain coverage, so it intends to be proactive in helping members of the public understand their state health insurance options, such as whether they may qualify for subsidies to help pay for coverage and how to enroll.In many states, the navigators have not yet been identified. When they are, Trinity Health representatives will build relationships with navigators with the goal of enrolling as many eligible consumers as possible. In addition, the health system is creating its own educational materials to help consumers learn about the insurance marketplaces in their state, and Trinity may offer to help consumers enroll. (While the ACA prohibits health systems from being paid as official navigators, it does allow health systems and others to help consumers use the insurance marketplace website to enroll.) In Massachusetts, Gee says, consumers were confused about their insurance options even though the state had a big educational campaign. For many who are newly eligible for insurance coverage, basic terms like “copay” and “deductible” must be explained before they can begin to choose a plan. Others who have traditionally had insurance through an employer will struggle to choose among a broad array of cost and coverage options, some of which require a big out-of-pocket responsibility. “We are talking about a different dynamic with individual purchasers, and a lot of upfront education and clarification is going to be very important,” Gee says. “Providers are going to realize that it’s a different day.”
Lola Butcher is a freelance writer and editor based in Missouri. Interviewed for this article:Preston Gee is senior vice president of strategic planning and marketing, Trinity Health, Livonia, Mich.
Forum members: Please share your insights, questions, and comments about this article. You can use the "inshare" button at the top of this web page or visit the Payment and Reimbursement Forum LinkedIn discussion board.
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Publication Date: Wednesday, May 22, 2013
In this business profile, Amy Gross, senior vice president of Key Government Finance, discusses the benefits of private placement transactions to support large-scale financing projects.
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.
In this business profile, Doug Polasky, executive vice president at Xtend Healthcare, explains the importance of having sound workflow processes in a consolidated business office to ensure optimal performance and reduce costs.
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.
TriMedx helps health systems control costs and uncover savings opportunities by optimizing the clinical engineering function.
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.
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.
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.
Emad Rizk, MD, president and CEO of Accretive Health, discusses the uncertainty facing hospitals and the transitions affecting revenue cycle management.
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.
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.
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.
Steve Scibetta, senior director of channel sales for Ontario Systems' healthcare product line, shares insights into effectively managing receivables.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
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.
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.
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.
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.
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.
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.
Greg Burgess, Founder and Chief Product Officer at Burgess Group shares insights and opportunities for payment integrity in the rapidly changing healthcare IT landscape.
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.
Copyright 2016, Healthcare Financial Management Association.
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