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The Forum's first virtual networking event, on Feb. 23, 2012, gathered three experts to discuss the 2014 launch of state-based health insurance exchanges under the Affordable Care Act-and how healthcare finance leaders can prepare for these exchanges.
This is a sample article from HFMA's Forums. It sums up the key take-aways from a virtual networking event for Forum members that was held in February 2012.
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After a brief overview of the exchanges by HFMA's Jim Landman, director, thought leadership initiatives, the virtual event focused on lessons learned from the Massachusetts' exchange, which launched in 2006. Two of the speakers-Jon Kingsdale and Patrick Holland of Wakely Consulting Group, Inc.-were involved in the set up of the Massachusetts' exchange. The third speaker, Richard W. Silveria, senior vice president and CFO, Boston Medical Center, provided a healthcare finance leader's perspective on how the exchange has affected his hospital and the hospital's revenue cycle operations.
Below are the key take-aways from the event.
The exchanges will likely encourage price comparison-and price compression. A major component of the Massachusetts' exchange is the
Health Connector website, which allows individuals and businesses to shop for insurance plans. In Massachusetts, both small group and individual plans are sold via the exchange.
"The website is fairly simple to use for shopping," said Kingsdale. "You enter a few pieces of information, such as your geography, age, and the kind or tier of coverage you want, and up pops a half dozen packages. All of these plans offer pretty much the same coverage but differ quite a bit in price."
Take a 37-year-old single person. As of last year, this consumer could find health plans on Health Connector that varied from $242 to $381 a month, said Kingsdale. "If an exchange does nothing else, it should simplify comparison pricing and will probably make price king," he said.
As price transparency increases in Massachusetts, the state's providers are gearing up for price compression. "This [individual/small group purchasers] is a very price sensitive market segment," said Silveria. "Negotiated rates tend to be benchmarked to public payer rates."
So far, the commercial products being sold on the exchange have not yet had a large impact on employers dropping current health plans. However, the Massachusetts' government has made premium affordability a priority in recent years, which seems to be indirectly impacting rates, said Silveria.
"There is a lot of rate compression in Massachusetts. But it depends on who you are and how much market clout you have. Some of the more powerful providers that were able to get better rates are going back to the table and renegotiating deals before they are up in anticipation of dislocation in the market related to price and quality."
The exchanges may stir major market shake ups. "Massachusetts has seen a tremendous amount of activity in the private market between health plans and provider groups, which are inventing limited or tiered network products and moving into capitated and global arrangements," says Kingsdale.
The introduction of the Massachusetts' exchange as well as other state health reforms has spawned numerous consolidations, mergers, and insurance product launches in recent years. Here are a few examples:
"There has really been a shake up," said Kingsdale, pointing out that Massachusetts had a competitive market to begin with. "If this is going to carry through to states with one-hospital towns, it is hard to know. But in geographies where there are competitive provider systems, we are seeing a whole new mindset. Providers who played the game beautifully-that is, by getting as much market share as possible and leveraging as much from health plans as possible-are all of a sudden thinking, 'Gosh, I'm going to lose patients if I don't cut my prices.'" This probably won't play out everywhere, but if the [market] situation is right, then you could see a 180-degree turn to much more efficient, tighter relationships with a limited number of providers and health plans participating."
Most states will probably go with the passive exchange model-at least at first. The state exchanges can be completely state-run, run initially as state/federal collaborations, or federal-run for states with no interest in running their own, explained Landman. States that choose to run their own exchanges may choose to be either "passive" purchasers (i.e., certifying any plan that meets minimum criteria) or "active" purchasers (i.e., selecting plans based on additional cost and quality criteria).
Massachusetts has selected an active model, which may partially explain some of the market shakeups as payers and providers try to differentiate themselves on cost and quality. Three other states have also chosen an active model: California, Connecticut, and Oregon.
At this point, however, these four states are the exception. "As part of
HFMA's Value Project, we've had conversations with a number of payer representatives, and indications from them is that most states are just trying to get these exchanges started," said Landman.
Once states learn the ropes and get their exchanges operating, this may change, said Kingsdale. "Robust competitive markets could get more selective over time."
Hospitals may need to invest more in financial counseling. At Boston Medical Center, patient access and financial counseling were the revenue cycle areas most impacted by the launch of the Massachusetts' exchange. "We had to beef up our staffing and the education level of our financial counselors," said Silveria.
Patients are first screened via a state-provided Medicaid eligibility IT application, which also assesses patients' eligibility for other state-subsidized programs. If patients do not qualify for subsidized care, the financial counselors point them to the exchange's Health Connector website and educate them on how to select and enroll in a health plan.
"In some cases, patients will select or get defaulted into programs that your [hospital] might not have contracts with," said Silveria. "If they end up out of network, you have to work with the patients to move the care to in-network providers." Boston Medical Center is also working to increase the number of payers it contracts with, he added.
Information exchange and automated enrollment will be key. For the exchange to function properly, a lot of information has to flow among providers, carriers, and regulators, said Holland. "This is kind of common in Massachusetts, but the availability of data from carriers is not widely available in other states."
"The exchange needs to be really plugged into and interoperable with the qualified health plans' systems," added Kingsdale, "so there can be a smooth, instantaneous set of transactions that occur with enrollment in a health plan on the website. Some plans will be able to do it and others will not."
From the provider's perspective, it comes down to real-time automated enrollment-for both Medicaid/subsidized programs and for commercial plans sold on the exchange, said Landman.
The federal government is providing capital to states through 2014 to build all the IT systems for the exchanges, including Medicaid eligibility systems, said Holland. "A lot of states are getting after this, and the focus is on Medicaid eligibility systems and how that relates to the exchange. Should they build something completely new or leverage an existing system? It will be very important for the exchange to get it right the first time."
Increased churn will be a reality. Shifts in patient eligibility for Medicaid and other subsidized coverage is expected to increase substantially after three core elements of the Affordable Care Act-insurance exchanges, expanded Medicaid coverage, and insurance subsidies-go into effect in 2014.
Silveria confirms that his hospital did see more churn after his state's exchange launched. "There is a fair amount of churn, as patients go in and out of different classes, in terms of whether they lose their jobs or get jobs and no longer need subsidized care," he said. "You find yourself in a role of helping these people navigate through this, and working with payers to make the change more seamless."
Access related material from the Forum's virtual networking event:
The on-demand recording of the Forum's virtual networking event, "Preparing for the Health Insurance Exchanges"
Slides from the event
A list of HIX questions for finance leaders
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.
Converse and network with your peers around vital topics.
Drive down costs while improving quality in a reform environment.
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