HFMA Roundtable Participants
Shannon Carey is director of patient access/revenue cycle for Gundersen Health System in La Crosse, Wisconsin.
Marc S. Cohen is CFO of University of Rochester Medical Faculty Group for University Rochester Medical Center in Rochester, New York.
Stacy Collins is assistant vice president of patient access services for Ochsner Health System in New Orleans, Louisiana.
Nicole Fountain is vice president of revenue cycle for University Chicago Medical Center in Chicago, Illinois.
Stephanie Franz is revenue cycle/patient access director for Tampa General Hospital in Tampa, Florida.
Vincent Martino is co-founder and chief product officer for VisitPay in Boise, Idaho.
Carol A. Ott is united business office director of University of Rochester Medical Faculty Group for University Rochester Medical Center in Rochester, New York.
Michael L. Taylor is vice president of strategic pricing and reimbursement for Cincinnati Children’s in Ohio.
It’s common knowledge that the patient financial experience matters. But how do the leaders of a complex revenue cycle evolve their organization’s approach to both enhance patient satisfaction and improve financial outcomes? In this roundtable, a group of senior revenue cycle leaders discuss:
- The importance of keeping the patient top of mind
- How to achieve the trifecta of increased yield, higher patient satisfaction and lower administrative costs.
What is driving the need for a more consumer-centric approach to the revenue cycle?
Carol Ott: Many evolving forces within today’s healthcare ecosystem, including concerns about quality, value, access to care and increasing costs, are pushing providers to adopt a more consumer-centric approach to clinical and financial operations. Moreover, as out-of-pocket expenses continue to rise, consumers expect to pay their bills with the ease and convenience of other industries, such as retail and banking, and are becoming more cost-conscious. Providers will need to be increasingly transparent around costs and offer greater convenience to best meet consumer needs and remain competitive.
Nicole Fountain: As patients’ financial responsibilities increase, providers must collect more money directly from individuals, which is difficult to do, especially if patients don’t understand what their costs will be. As such, estimates need to be accurate, billing statements must be clear, and providers should make it easy for patients to pay by offering a range of options. If patients don’t understand what they owe, or providers don’t offer convenient payment methods, patients may either choose not to pay or they may select a different provider the next time they need healthcare. In addition, when self-service payment options are available, they allow staff to focus on more complex cases that require personalized assistance while making it easier for those who wish to self-navigate.
Shannon Carey: Another factor is that competition in healthcare is increasing, especially with the rise of nontraditional delivery models, such as telehealth, virtual visits and retail clinics. As patients owe more, they are starting to price shop before selecting a provider, considering some of the nontraditional options as possibilities. This means healthcare entities have to offer superior services at a superior price to remain competitive.
Marc Cohen: Consumers want easy access to their healthcare experience. They have come to expect convenient, one-touch functionality to get what they want in nearly every other industry, and things are now carrying over into healthcare. We need to be able to deliver this level of functionality if we’re going to remain competitive over the long term.
Stacy Collins: At Ochsner Health System, we’ve been implementing different ways to improve the registration and check-in processes to enhance the patient’s financial experience overall. Individuals can check in with registrars and kiosks, and even check in at some of our facilities with our portal app via mobile. Through the portal, patients can also run estimates and sign forms ahead of their appointments. Like online retail shopping, patients can save credit card information in their accounts, so paying co-pays and residual balances is fast, easy and straightforward.
What are the key components to creating an excellent patient financial experience?
Michael Taylor: At Cincinnati Children’s, trust is fundamental. Before patients, or in our case families, can trust the financial experience, they must trust they’ve had a top-notch clinical experience. They want transparency around their care and costs and to appreciate that what they’re paying is appropriate. We’ve worked closely with families through a family advisory committee to structure processes, billing statements and the patient portal to enhance trust and enable transparency. Our billing statements are clear and concise, spelling out what the health plan covers and what the patient’s out-of-pocket responsibilities are.
Collins: Letting patients know their financial obligations before they arrive is also valuable. Ochsner Health System has a pre-service team that alerts patients to their out-of-pocket expenses by calling or messaging them. We also have financial counselors who can speak to patients before or at the time of service about larger balances. This gives an individual the ability to map out a financial plan if needed. We also have a way for patients to “shop” our services and upload accurate estimates through the portal at their convenience.
Stephanie Franz: Patient education is another essential component. Organizations should take the time to have financial discussions with patients, make them comfortable and wholly engage them to ensure they are aware of their responsibilities and payment options. Doing so in advance, when possible, or at the time of service, promotes a better billing experience. Moreover, when interactions are consistent and dependable, it builds trust. If patients know they are going to engage in financial conversations and these discussions will be accurate, they are more likely to believe the organization and try to meet their obligations.
Cohen: An excellent financial experience starts with knowing the patient and understanding his or her insurance. At University of Rochester Medical Center and Faculty Group, we see a wide variety of patients with the full spectrum of coverage, ranging from entirely self-pay to complete coverage. We also care for patients from nearby Amish communities, which have different rules for care and financial obligations. By making sure we understand patients’ coverage, we can accurately explain their benefits and address their questions and concerns.
Ott: I agree. Patients expect the provider to know their benefits and what’s covered, and they rely on us to navigate the financial aspects of care for them. Healthcare is unlike almost every other industry because you don’t always know what services you’re going to need upfront, which is why it can be difficult to improve transparency.
What are some of the challenges associated with moving to a consumer-centric revenue cycle?
Taylor: A big issue is that healthcare tends to operate in a provider-centric mode, where appointments and procedures are scheduled for the convenience of the physician, staff and organization — not the patient. Yet, today’s providers need to meet consumers’ demands to remain competitive. This may mean extending hours to evenings and weekends and appropriately staffing call centers to scale peak times, so that someone is available when the patient needs help. We work with families of children with complex medical conditions who often need to see multiple specialists and want to schedule those visits in a single block of time on the same day to minimize the number of trips they have to make.
Ott: Many healthcare organizations still operate in silos where information systems are not fully integrated. It’s important, however, that different operational departments that interact with the patient, such as scheduling and revenue cycle, collaborate to provide a more patient-centric experience. If they don’t, the patient may receive conflicting messages, which can taint their overall impression of the encounter.
Cohen: Managing a wide range of patient expectations and consumer types can also be tricky. A patient’s age, education, health and technology skills impact their expectations, and what works for one patient may not work for another. To fully match everyone’s abilities, respect their preferences and meet their expectations, it requires a lot of effort and resources.
Vincent Martino: Healthcare providers realize that one size doesn’t fit all when it comes to the financial experience. Giving patients financial offers that are tailored to their situation is becoming important in both increasing satisfaction and improving payment rates over time.
Carey: At Gundersen Health System, we offer multiple ways for patients to communicate with us — via the patient portal, instant messaging, phone and face-to-face options. All of these require people to staff them. So, it can be difficult to find the right balance between giving patients what they need and overstaffing the various resources.
Fountain: Almost every revenue cycle initiative is powered by technology, which means our projects become IT projects as well. There are many IT projects in the queue, and one of our biggest hurdles is balancing the demand for improvement against available resources and prioritizing which areas receive attention.
Franz: Continuing the technology theme, developing a consumer-facing platform that patients want to use and can easily adopt can be a tall order. The right tools enhance an individual’s experience rather than detract from it by being accurate, intuitive, efficient and reliable. Our patient portal offers a convenient, seamless experience for patients where they can schedule appointments, review lab results, communicate with providers, pay their bills and set up payment plans all with one login.
Another big hurdle is helping patients understand why independent providers, such as radiologists, anesthesiologists or surgeons, might bill separately from the hospital for the same encounter. At Tampa General Hospital, we’ve launched the Billing Ambassador program, which helps patients navigate the complexity of healthcare billing, even when bills are not generated by us. Ambassadors are staff members who communicate with community providers on a patient’s behalf to clarify their billing concerns. Patients can contact our billing ambassadors directly with questions or they may be referred to an ambassador by their provider.
Collins: Getting patients to adopt new processes or technology, such as kiosks for check-in, sometimes can be a struggle. When we implemented kiosks, patients initially were hesitant to use them, because they thought the tools were going to take jobs away from employees. We had to assure patients that this was not the case, and that the kiosks are designed to allow staff to spend more time with patients who need the extra attention while allowing others to self-serve.
What other areas/departments within your health system are important to engage to drive improvement? What role do they play in cultivating the patient financial experience?
Franz: The patient experience starts with scheduling and patient access, and these functions must educate individuals right from the start, helping them understand what their insurance covers as well as their financial responsibilities and options. Physicians and their support staff are also important to engage, so they understand the effects their practice patterns have on billing and payment. The more clinical staff are aware of the financial aspects of care, the more they can avoid putting the patient in a financially challenging position.
It also is critical to engage the IT department because technology, including the electronic health record (EHR), patient portals and other tools, are vital to delivering a consumer-centric experience. Before an organization purchases new technology, especially solutions that have a patient-facing component, they should engage in a 360-degree evaluation that ensures all stakeholders’ needs are met.
Collins: Yes, engaging IT is crucial. When implementing our electronic check-in tool, we wanted to create a more seamless experience; we worked closely with IT so patients would have the ability to sign forms within the portal, in addition to paying co-pays and other payments online before they arrive for their appointments. We also work closely with scheduling and patient access to streamline processes and reduce redundant questions. We received feedback from patients that it was frustrating to answer the same questions over and over, and we have tried to limit duplication as much as possible.
Taylor: Patient access and scheduling are families’ first encounters with the hospital, so they must be patient focused. We combine scheduling and registration into “schegistration,” where families can schedule appointments, obtain estimates, get directions to the hospital and learn what to expect in the same call. For families with complex needs, we can assign a family financial advocate, who can help them navigate the financial aspects of their encounter.
Martino: As providers put more emphasis on point-of-service collections and use of estimates, it is important to connect, in a seamless way, the patient’s initial billing experience with what happens after service and insurance adjudication, for both the patient and the revenue cycle team.
Carey: Marketing plays a chief role in promoting new services and helping us reach our target audiences for different campaigns. For instance, we recently changed our self-pay vendor, so patients can make payments directly through their patient portals rather than having to go to a different online account. Marketing was pivotal in alerting patients of this change through mail, email, the patient portal and website, in addition to producing on-site signage and brochures. By optimizing our existing technology, patients now have a much easier and convenient way to pay their bills, which increases their satisfaction.
Martino: We see marketers and patient-experience leaders getting more and more involved in the financial process. Partly this is to help drive adoption of new systems and processes. It is also to use data and analytics to understand and reach patients in ways that make sense to them. Finally, we see healthcare marketers using techniques like Net Promoter Score to measure patient loyalty, recognizing that the financial encounter can be as important as the clinical encounter.
Do you have examples of “wins” or successes achieved since shifting to a more consumer-centric financial experience?
Taylor: Cincinnati Children’s started moving toward a family-centric experience and consolidated our billing statements in 2007. In 2010, our billing satisfaction was roughly 50%, and 1% of calls, about 90 per month, were pricing complaints. We added additional tools, restructured patient access to be more family-focused and considered ways to reduce prices. Now, billing satisfaction is more than 70%, and less than 0.10% of calls are pricing complaints.
Carey: Shifting to a patient portal for cost estimates and the self-pay experience has been a cost-savings for Gundersen Health and a patient-centric win. It allows us to efficiently collect more money upfront and offers one, true account balance in real time. It’s also more convenient for patients, who can use the same tool for medical and billing information.
Franz: Tampa General Hospital’s big initiative has been to increase point-of-service collections to help reduce cost-to-collect. To achieve this, we provide comprehensive training to our patient access staff, which includes how, when and why to educate consumers about their financial experience. In addition, we set targets for point-of-service collections. Establishing expectations for creating a world class patient experience combined with the pressure to achieve our point-of-service collection goals, has led to higher patient satisfaction scores and a rise in year-over-year collections. In 2015, we collected $5.4 million upfront and received satisfaction scores of 90.9% and 89.3% in the main hospital and emergency department (ED) respectively. In 2018, we collected over $9 million upfront and satisfaction scores were 91.7% and 90.3%.
What are some lessons learned you would share with others looking to take on this endeavor?
Collins: Having a greeter at the point of registration who can appropriately triage patients to either a registrar or kiosk helps avoid patient frustration and optimizes staff. Since kiosks cannot accept checks or check in new patients, they are not meant for everyone. However, for those individuals who are returning patients using a credit card, it can provide an efficient option.
Franz: Ensuring you have the right people in the right jobs is key to providing a patient-centric experience. If the job description requires people to interact with patients and engage in potentially sensitive conversations, you want to be sure the staff person filling the role is comfortable with that activity. Robust training is also crucial so staff understand how to approach a patient, answer financially related “why” questions, and deliver education that provides clarity to patients and answers their questions.
Fountain: Oftentimes, over-communicating can help ensure staff understand the “why” behind patients’ financial obligations. You cannot just train once and expect staff to be able to speak to patients confidently about their bills and what their responsibilities are. Do not underestimate the power of a story; it’s such a natural and powerful way that humans communicate, and stories stick with people longer than straight facts and figures. Negative stories, in particular, can spread rampantly and cause trepidation among staff. Conversely, sharing positive stories, where patients felt supported in their time of need, can help staff feel more connected to the caregiving process and inspire your team to provide a truly great patient-centric experience.
Taylor: Listening to the customer and adapting processes and systems to their needs is essential. Getting your frontline staff’s perspectives is also wise, as they can provide valuable insight and help generate patient-centric ideas. For instance, the family financial advocates at Cincinnati Children’s was an idea brought to us by frontline staff who were seeing families struggle with the financial aspects of care. This program helps families, particularly those managing complex or chronic conditions who are reaching the limits of their health plan coverage, understand their bills, set up payment plans and navigate financing options and assistance.
Cohen: Before implementing a new system or tool, make sure it has been tested from the consumer’s perspective. You may think you understand what’s helpful to the patient, but unless patients test it, you don’t know for sure. Getting this kind of feedback can happen through focus groups or small groups of employees who test the tool as patients. After receiving patient buy-in, you should also consider the perspectives of others who will be touching the technology, such as system administrators, billing staff, customer service and so on. You want to gain an appreciation of how the system will interact with different processes and workflows.
Carey: Achieving a fully patient-centered experience is not something that happens overnight. We must understand our limitations and focus on areas that will make a meaningful difference. While it may be tempting to tackle what’s easiest to implement, and there is a benefit to addressing the low-hanging fruit, simplicity can’t be the primary reason for choosing an initiative to pursue. The biggest consideration should be whether a new idea helps patients, improving their satisfaction and elevating their experience.
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