Baylor Scott & White Revamps Patient Payment Processes, Saves $1.5M in Agency Fees

In response to the growth of consumer-driven health plans, Baylor Scott & White rolled out new processes and technology to enhance patient financial communications.

Dallas-based Baylor Scott & White Health continues to refine its revenue cycle processes to provide greater price transparency to patients and protect its bottom line against bad debt. In particular, the rise in consumer-driven health plans has prompted revenue cycle leaders to enhance the health system’s patient financial communications and step up point-of-service (POS) collections across the 48-hospital system, says Sarah Knodel, system vice president, revenue cycle.

“We want to make sure our staff are equipped to have financial conversations with our scheduled patients in advance of care and with our emergency department and walk-in patients at the time of service,” she says. “At the same time, we are increasing the focus on up-front collections. We’ve put in better processes and technology to improve post-discharge collections.”

Changing to a Price Transparency Culture

Knodel oversees five direct reports with more than 1,700 revenue cycle employees in access services, revenue integrity, clinical resource management (including utilization review), revenue cycle improvement, and the central business office. The health system’s 550-person central business office handles billing and collections, customer service, cash posting, and credit balance adjudication for its hospitals and clinics. All local hospital registration and financial counseling personnel report to their local access services leader, who reports directly to a corporate leader responsible for access services. A centralized access services department handles insurance verification and preregistration for the health system’s hospitals and clinics and performs outpatient diagnostic scheduling for the north Texas division facilities.

During the past five years, Baylor Scott & White’s vast revenue cycle infrastructure has undergone a cultural shift to promote better price transparency and leverage automation whenever possible. For example, preregistration staff now use an automated dialing platform to contact patients up to two weeks before their scheduled service. The team also leverages the use of an automated price estimation tool to help patients understand their out-of-pocket costs for their upcoming service.

“We recognized that if we were going to have more conversations with patients about their financial responsibilities, we needed to do it in the most efficient and accurate way possible,” Knodel says.

Price shoppers also can receive an estimate if they call the health system’s dedicated price estimate line or submit estimate requests via an online form on the health system’s website.

In addition, the health system’s north Texas facilities rolled out a patient-facing tool that allows patients to obtain real-time estimates online. Patients enter basic demographic and insurance information and select a service or enter a CPT code to generate an instant estimate based on their unique benefits.

Adding these tools required changes to workflows at the facilities to accommodate more comprehensive financial discussions with patients who did not complete the preregistration process or were walk-in patients.

“We recognized that if we could register these patients in advance, it would change the process for the patient on the day of service,” Knodel says. “One of the selling points for patients to preregister with us in advance of their care was an expedited check-in process on the day of service that would get them to their treatment more quickly. So, we also had to change processes at the facility because if we were processing all of these patients in advance, we wanted them to be expedited at the facilities and not have to go through a lengthy registration process. We were able to leverage kiosk technology for simple check-ins because the full registration was already completed in advance, and we were able to create a quick check-in process at the desk for patients who did not want to use kiosks or were in a location where they were not available.”

Preparing for a Different Type Of Patient Interaction

Beyond streamlining preregistration, leaders at Baylor Scott & White were driven to improve the patient experience. “It’s no longer acceptable to send a bill that becomes a huge surprise and burden to that patient after receiving service,” Knodel says.

“We believed we needed to improve the patient experience, which required a change in culture for our employees. When we started to have those conversations about the patient responsibility prior to care or at the point of service, patients came to appreciate it and expect it as well. If patients are seeking care from us, regardless of the setting, we need to help them navigate the financial process and understand their insurance benefits and how those benefits, coupled with our pricing and contract rates, impact the out-of-pocket costs associated with their care.”

The most challenging part of the culture change was overcoming some employees’ resistance to having financial conversations with patients. Some staff were uncomfortable having these discussions or were concerned that they did not have time to build these conversations into their workflow. Some managers also had concerns about staff productivity, patient throughput, and juggling the pricing transparency initiative at the same time they were standardizing their processes after the 2013 merger between Baylor Health Care System and Scott & White Healthcare. At the time of the merger, Baylor leaders had already implemented the price estimation tool and revised preregistration processes in their north Texas division facilities. Several years after the merger and integration of revenue cycle operations, leaders began to roll out the new tool and processes to their facilities in central Texas, which had been part of Scott & White Healthcare.

Standardizing these processes across the enterprise is still ongoing, Knodel says. “Our hospitals are far along in their integration efforts, but areas like our clinics are in the earlier stages of their pricing transparency journey,” she says. But early results suggest these efforts can have significant returns.

“For facilities in the north Texas division, we’ve seen a 60 percent increase in POS collections by the preregistration department,” Knodel says. The health system also has significantly improved POS collections in emergency deaprtments (ED) in its central Texas division. “In some cases, we are seeing a 75-plus percent increase in collections per visit at various facilities,” she says.

Knodel believes contacting scheduled patients about their out-of-pocket responsibilities further in advance of their procedures also has improved physician satisfaction. “Previously, if we didn’t have that conversation until the day before or the day of service, the patient might cancel after learning about the out-of-pocket cost, leaving an open spot in the schedule,” Knodel says. Now, preregistration staff contact patients up to two weeks in advance, making it easier to fill spots in a physician’s schedule. “By contacting patients further in advance and helping them understand what they will owe and what their options are to satisfy the balance, we have had a decrease in patient complaints and an increase in physician satisfaction related to this process,” she says.

Boosting Internal Payments

As part of their revenue cycle culture change, leaders at Baylor Scott & White also enhanced the post-discharge collection process—and as a result, reduced the cost to collect. “With the implementation of automated dialing technology that reminds patients when they have an outstanding balance while the accounts are still on the A/R, we were able to cut collection agency fees by $1.5 million in one year,” Knodel says. Before making the change, a sizable portion of accounts were collected within 60 days of placement. “We realized we needed to be more proactive, and we saw a 100-plus percent increase in our monthly internal collections post-discharge.”

Knodel says her staff has received positive feedback from patients who value the opportunity to speak to someone at Baylor and resolve the issue before their accounts are moved into collections.

Sharing Lessons Learned

Knodel provides the following suggestions for revenue cycle leaders implementing new processes to promote price transparency and improve collections.

Create staff liaisons with IT and vendors. Baylor Scott & White’s revenue cycle services department served as a liaison between IT, revenue cycle operations, and software vendors during the implementation of bolt-on revenue cycle applications. This expedited implementation efforts.

Make staff training a priority. Leaders at Baylor Scott & White leveraged the internal consultants in their revenue cycle improvement department and trained “super users” at each facility on the new processes.

“We take a hands-on approach when rolling out new technology to ensure people understand how to use it as well as the expectations around scripting,” Knodel says. “You can’t implement technology and think it is going to solve problems when you don’t change processes or people’s behavior.”

Add more payment options for patients. After adding the patient estimator tool, leaders at Baylor Scott & White wanted to offer more payment options to patients to help them resolve balances. To that end, they implemented an interest-free patient loan program and enhanced their financial assistance process by leveraging third-party data for verifying patient’s income and household size, resulting in real-time charity qualification for patients over the phone and in-person.

Use metrics to create accountability.  “For any implementation, it’s important to make sure you hold people accountable to the new process and determine how you will measure success,” Knodel says. Baylor Scott & White revenue cycle leaders track POS collections, collections as a percentage of estimated opportunity, collections per ED visit, and the percentage of accounts in a given day by location where financial conversations occurred with patients.

Make sure prices are defensible. Baylor Scott & White’s revenue integrity department maintains the chargemaster and is responsible for pricing across the system. “We complete an annual pricing defensibility study, which enables us to review our prices relative to other competitors in the market. Our goal is for our pricing to be transparent and defensible,” Knodel says.

Make bills more patient friendly. To further improve the patient experience, leaders at Baylor Scott & White have revamped their patient financial statements. “We’ve made them more patient friendly and added color to help draw patients’ eyes to key information,” she says. They also have implemented paperless billing. “Although we would like a higher adoption rate, it provides another way to engage patients in their preferred method of communication,” Knodel says.

Looking to the Future

In the coming months, leaders at Baylor Scott & White plan to add physician charges to their patient-facing price estimation tool so patients can get complete estimates for their episodes of care.

In addition, the health system is exploring using texts and e-mail messages to reach patients during preregistration as well as post-discharge. This will expand upon the health system’s recent addition of an online chat capability for patients who do not want to make calls. “We regularly monitor how many chats as well as incoming calls and e-mail messages are being sent into our department to ensure that we are responding in a timely manner to patients. The feedback from the chat functionality has been very positive based on the survey completed by patients at the end of the chat conversation,” Knodel says.

Interviewed for this article:

Sarah Knodel is system vice president, revenue cycle, at Baylor Scott & White Health, Dallas, and a member of HFMA’s Lone Star Chapter.