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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.
By Lola Butcher
Ever since consumer-directed health plans emerged, payers and policymakers have been advocating for a transparent marketplace in which patients can make purchasing decisions based on cost and quality data. For many patients, that day has arrived. Insurers, state governments, and vendors are introducing online tools and other services that allow patients to easily compare costs of hospitals and physicians.
Much of the cost information being provided is pulled from claims data. A growing number of states and not-for-profit organizations, such as
FAIR Health, have posted public databases that allow cost comparisons of common procedures/services, such as arthroscopic knee surgery. More sophisticated tools provide patients with tailored estimates that drill down into an individual's insurance plan, deductible, copays, etc.
This is still the experimentation stage of the healthcare transparency movement, says HFMA's Richard L. Gundling, FHFMA, CMA, vice president of healthcare financial practices. "It's evolving. Payers, providers, and patients are experimenting with information to see what will be used in decision making."
See related article: Lessons Learned from Hospital Transparency Pioneers
A number of health plans are experimenting with various approaches to encourage members to use cost information in choosing providers.
Online tools. Cigna recently launched an online service that allows health plan members to compare physicians and hospitals based on price for more than 200 medical procedures. The Cigna site also provides quality information on providers.
View Cigna screenshots
The Cigna service allows health plan members to assess medical costs, including specialist, facility, and ancillary fees. "You can look up a knee arthroscopy by doctor and get a precise estimate for what you will pay to get care through that doctor-that includes not just the doctor's fee, but also related services such as diagnostics and anesthesia, as well as hospital or facility costs," says Jim Nastri, Cigna's vice president for cost and quality transparency.
The service takes into account the patient's current deductible status and coinsurance responsibility and provides an estimate of the patient's payment responsibility. It also assesses the balance in the patient's health spending accounts.
The cost information is pulled from medical claims in the past year. Cigna claims that their tool has an accuracy rate of within 10 percent of the patient's cost 90 percent of the time.
Incentives for shopping. Harvard Pilgrim Health Care, with members in Massachusetts and New Hampshire, is providing financial incentives for members who search out lower-cost options for elective outpatient procedures and diagnostic tests. Members can call the insurer's SaveOn program before choosing a provider for a colonoscopy, CT scan, mammogram, or other service. A SaveOn nurse helps members identify the low-cost providers, helps with any paperwork needed to use those providers, and makes scheduling changes, if needed. In addition to lower out-of-pocket costs, members receive up to a $75 reward for using SaveOn, depending on the cost savings achieved.
Some Anthem Blue Cross and Blue Shield members in three states have access to a similar service called Compass SmartShopper. Members can find low-cost providers for certain diagnostic and elective services on a website or through a telephone call. Patients who choose a less-expensive provider than their physicians recommended will receive a check for between $50 and $200, depending on the savings.
Although the information that allows for comparison shopping is becoming available,
most patients are not yet choosing providers based on cost, says Gundling. Traditionally, most patients have relied heavily on so-called "trusted advisors" who recommend physicians and hospitals-and that continues to be an important influence on patient choices.
"That $100 or $50 difference in costs doesn't make as much difference as if your best friend had good results with a certain provider for the same procedure," says Gundling. "Patients think, 'I'll see that doctor, too.'"
A recent Health Affairs study backs up Gundling's assertion. Researchers cited several reasons for why patients are not accessing public cost reports ("Consumers' and Providers' Responses to Public Cost Reports, and How to Raise the Likelihood of Achieving Desired Results," Health Affairs, vol. 31, no. 4, April 2012):
Gundling compares healthcare purchasing decisions to the ways shoppers use a different value equation at Target than at Nordstrom. "Target and Nordstrom could offer the same silk scarf from the same manufacturer, but when you go to Nordstrom, you are willing to pay more for it-and you feel like you got better quality because you paid more for it," he says.
All of this likely explains why hospitals have not been at the forefront of cost transparency: Their patients are not demanding the information.
However, while most patients are not yet using cost to make high-value choices, they are gradually becoming more sophisticated consumers. "A couple years ago, not that many people were making distinctions between hospitals in terms of quality," says Joe Mondy, Cigna's director of public relations. "It was expected that quality was uniform or the quality for one type of procedure would be indicative of the hospital's quality for all types of procedures."
That is no longer the case. In developing its online tool, Cigna conducted focus group research that showed patients were very interested in quality scores when they were considering serious procedures that involved an inpatient stay, says Marie Jinks, Cigna's director of eBusiness. "When it came to a procedure that required an overnight hospital stay, patients really wanted to focus on the quality of both the doctor and the hospital where that particular procedure was performed," she says.
Based on that research, Cigna designed its online tool so that patients can see quality and cost ratings of physicians-and the various hospitals where those physicians work.
Gundling encourages hospital financial leaders to post cost or pricing information. Hospitals should encourage patients to become fully educated on their health plan benefits and what they can expect to pay for healthcare services.
Hospitals can help by providing information about a patient's expected financial obligations in writing-with appropriate caveats about what the pricing estimate does and does not include. "The first step is to provide something," he says. "If you can't provide any information, people are very distrustful."
Focus on making pricing information as simple as possible, Gundling continues, which will benefit patients as well as their employers and insurers. That is its own competitive advantage in the marketplace, he says.
Finally, figure out the best way to communicate the value that your health system delivers. "We all go shopping, and we know that value means getting the highest quality for the best price," says Gundling. "But as patients, we haven't figured out what we want yet."
Lola Butcher is a freelance writer and editor based in Missouri.
See related article: Lessons Learned from Hospital Transparency Pioneers
Publication Date: Thursday, May 17, 2012
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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