Reimagining Patient Access

As patients take on greater responsibility for paying for their healthcare services, they need information that health systems and hospitals traditionally have not provided, such as how much patients will be expected to pay and what their payment options will be. However, forward-thinking organizations are starting to improve their patient financial communications with the goal of engaging individuals about their obligations earlier in the healthcare encounter. As part of this effort, health systems are shifting traditional back-end processes-including financial clearance and counseling-to the front end, incorporating them into the patient access function. With this in mind, participants in this HFMA Executive Roundtable, sponsored by Allscripts, share their experiences in retooling patient access to better communicate with patients about their financial responsibilities.

How has your organization's approach to patient access changed in the past few years?

Melissa Viohl: Chesapeake Regional Medical Center (CRMC) has been redefining patient access in a real way over the last year. Culturally, we are educating our registration staff about the idea that they are not just "name and address takers," but make up a full-service department that helps patients understand their insurance and payment responsibilities.

Before 2015, point-of-service collections were a nicety for our organization, and processes to collect money up front were inconsistent. Now, after six months of staff training and implementing estimation and collections technology, we have a robust point-ofservice collections program. This includes a financial stewardship component that allows our registrars and financial counselors to help patients manage their obligations. We screen patients for Medicaid eligibility, assist them with financial aid applications, and/or arrange for other payment options.

Diane Watkins: The more information we share with patients, the better prepared they are for meeting their responsibilities. For example, we find it valuable to explain to patients what their benefits are, let them know an estimate of what they might owe for a service, and discuss our pre-payment requirements so that they understand what to expect during the billing process and what their options are.

We started becoming more proactive about patient financial communications in 2011, reaching out to patients and providing price estimates-and we have seen some great results. In 2010, we only provided about 2,500 price estimates, and last year we delivered 40,000. We have pretty much doubled point-of-service cash collections during this time, from about $3 million to approximately $6 million.

Richard Baney: A few years ago, Health First started talking with patients up front about payment, clearly explaining that most services require cost-sharing, and we expect a portion of that payment in advance, especially for the bigger-ticket services, such as surgeries and diagnostic studies. For example, when a patient goes to the surgery scheduler, he or she has a conversation with the scheduler right there about what the patient's expected cost-share is going to be. It's all up front, so there are no surprises.

About four years ago, Health First created a financial clearance department to answer patients' questions about insurance benefits and develop new strategies to help them with hospital payments. Patients undergoing elective procedures can comparison shop for prices by calling Health First's pricing hotline. Consumers also have the option of consulting with one of Health First's 20 benefit advisers who can quickly assess a financial situation, whether the patient plans to self-pay or carries health insurance of some kind.

How do you incorporate industry best practices for patient financial communication in your front-end processes?

Sandra Wolfskill: HFMA's patient financial communications best practices were developed by leading experts to provide specific guidance to hospitals, health systems, physicians, and other providers to outline where and when conversations should occur, the appropriate content for those conversations, and who should participate. For example, in the Emergency Department (ED), patient financial interactions should not take place until after the patient has been medically screened in compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA). For unscheduled outpatient services outside the ED, the conversation should be part of the registration process. For scheduled patients, it should happen during the scheduling/pre-registration call with the patient and/or his or her representative.

Discussions should include a review of the patient's insurance coverage or lack thereof, the estimated cost to the patient for the service, and available options for coming to a financial resolution of the patient's obligation, including any financial assistance opportunities. Staff should also address any past encounters that remain unresolved. Depending on the complexity of the situation, it may be appropriate to involve a financial counselor to assist with the interaction.

Watkins: Saint Luke's has embraced HFMA's best practices and, in fact, many of those were already a part of our processes before HFMA published them. For instance, we make it a point in the ED to talk to patients about their copay-after they have been medically screened and stabilized, of course. And we even screen those patients for Medicaid or financial assistance while they are still with us in the ED.

Viohl: We use both HFMA and the National Association of Healthcare Access Management (NAHAM) standards to guide our front-end processes. Accurate pre-registration is the key to successful patient access, and we have been working diligently to implement a "Tier III/Tier IV" pre-registration unit. (NAHAM defines pre-registration tasks by tiers. Tier III tasks are "estimate patient liability" and "collect patient liability." Tier IV tasks are "screen for financial assistance," "arrange payment plan," "refer to financial resources," and "qualify and enroll for new benefits.") We currently have a 90 percent pre-registration rate, and we are seeing increases in our insurance verification, as well as accuracy rates. These improvements are the result of staff retraining and process retooling.

Ajit Sett: In addition to industry best practices, organizations are also wrestling with the new Internal Revenue Code 501(r) legislation. Demonstrable commitment to the practices outlined in the legislation is a requirement for 501(c)(3) provider organizations that operate one or more hospital facilities under the 501(r) legislation. Each 501(c)(3) hospital organization is required to meet general requirements on a facility-by-facility basis, including establishing written financial assistance and emergency medical care policies; limiting amounts charged for emergency or other medically necessary care to individuals eligible for assistance under the hospital's financial assistance policy; and making reasonable efforts to determine whether an individual is eligible for assistance under the hospital's financial assistance policy before engaging in extraordinary collection actions against the individual. A number of organizations are looking to technology to support compliance. Technology solution partners must enable the timely communication of policies, procedures, and benefits to consumers and the patient population. The Web and social media, in addition to leaflets, posters, and clearly defined and consistently adopted processes, are critical to the demonstration of the organization's commitment. In addition, there is a significant amount of training and education that must take place to make sure all communications are consistent.

How do you ensure that financial communications are understandable to the patient?

Jeff Hurst: One way is by revamping the patient estimate letter. We recently reworked our letter with the goal of accomplishing two basic objectives. One was to give a simple, understandable calculation for how we figure the patient out-of-pocket responsibility. We spell out the patient's estimated allowable, which we determine based on our contract with the individual's insurance company. We also list the patient's deductible, coinsurance, and copay. The letter walks the patient through a mathematical calculation, ending with a final number, which is a realistic approximation of the amount the patient is ultimately going to owe.

Second, we wanted to create awareness and education around a patient's insurance benefits. In the last couple of years, since open enrollment for health insurance exchanges began, having a clear idea of coverage limitations has become increasingly important because a lot of people now have insurance for the first time, and yet they don't really understand what they have- especially if they purchased one of the available highdeductible health plans. In these cases, although patients have insurance, they don't really have coverage unless they're admitted to the hospital-because the first $5,000 or the first $10,000 in costs are the patient's responsibility.

As we share information more clearly and concisely, we will gain patients' trust and participation. There is nothing but upside, in my opinion, when you've got both the patient and the hospital communicating with each other at a higher level.

When do you engage in financial clearance and counseling? How often do you have these conversations?

Viohl: We believe that every registrar is a financial counselor at some level, and we have built financial counseling activities into all patient access job descriptions as part of our efforts to elevate registration roles. For example, staff members at every level of account pre-registration and registration are expected to start dialogue with patients about their financial obligations. There are flags in our patient registration system that alert staff if a conversation has occurred and to what extent it was completed. It is imperative that pre-registration and other front-end staff communicate well so as not to frustrate the patient by continuously asking and/or providing the same information.

Watkins: We reach out to scheduled patients; we don't wait for them to call us and ask what they might owe. When we schedule a patient, our technology system populates a work queue in our financial clearance center. So, our process really starts there, with staff getting the patient pre-registered, verifying insurance, and providing a price estimate. We attempt to call patients prior to their scheduled procedure dates to let them know that we have completed their pre-registration, and that everything will be expedited when they arrive on site for the procedure or service. We also let patients know an estimate of what they might owe out of pocket and ask whether they want to pay now or make a payment arrangement.

We have a pre-payment requirement for uninsured patients who wish to schedule elective services and also for insured patients who are going to owe more than $1,000 out of pocket. We explain to these patients that they are going to be required to pay 25 percent of their estimated out-of-pocket costs up front. We offer to take that payment over the phone if they want to provide us with credit card information. If not, we tell them to be prepared to pay it at the time of service. For the remaining amount, they can set up a payment plan or pay in full when they receive their final bills.

Do you help patients understand the costs of a particular service up front? What information is necessary to do this?

Viohl: As part of an overhaul of our pre-registration unit during the last year, we implemented a point-of-service application that creates patient estimates and automates insurance eligibility confirmation. We use data integrated from the hospital information system and/or the order, along with information about the patient's insurance benefits.

Watkins; Our price estimator solution pulls information about our charges for a particular service and combines it with data from the managed care contract and the patient's verified insurance benefits, including his or her deductible and coinsurance status. We can then come up with a true estimate of the patient's out-of-pocket responsibility.

Sett: To generate realistic estimates, provider organizations need to have an integrated clinical and financial database. If this information is not in the same location, you are just guessing when you make an estimate.

What payment tools do you offer to allow patients flexibility in making payments? Are there particular methods you have found to be more beneficial than others?

Hurst: Historically, our approach was geared around payment in full, but over the last couple of years, we have transformed the conversation from collections to resolution. Oftentimes, there are patients who want to do the right thing, but they need a little bit more time or they want flexible payment terms. As such, we try to do a financial triage up front-even with our insured population-to assess the patient's ability to pay and how much time he or she will need. We are being a lot more flexible now in terms of payment options, whether it is payment in full for those who want to do that, short-term 90-day payment plans, or longer-term payment plans up to 24 months. For our longer-term payment plans, we use a vendor that is an industry leader in the patient-financing space. We've had a relationship with them for eight years. Up until about a year ago, we charged interest on payment plans. Based on the vendor's guidance, we changed that process and now offer interest-free payment plans up to 24 months.

Watkins: We also offer short-term, no-interest payment plans for up to six months, depending upon the amount a patient owes. And if someone wants to have more than six months to pay, we offer a bank loan program that will spread payments out for 36 months at a low interest rate. This makes it easy for the patient who wants that longer term to pay for his or her bill.

We manage the short-term, no-interest payment plans internally, but the longer-term program is managed by a well-established bank here in Kansas City. We do not have to refer patients to the bank; our customer service team is trained to set people up on the program. So, our staff can explain how it works and get the patient enrolled during that one phone call. In addition, the bank does not require a credit history or other qualification to participate in the program.

What Key Performance Indicators (KPIs) do you use to measure patient access performance?

WoHskill: Although there is not one KPI that covers the patient access area, there are several measures that are important to collect and monitor. For example, organizations should be reviewing percentage of scheduled services pre-registered; percentage of total registrations with verified insurance; percentage of self-pay cash collected at point-of-service; percentage of uninsured accounts converted to insurance source; and percentage of denials related to insurance issues. By keeping an eye on these metrics, organizations can create a picture of how well they are obtaining patient information up front, verifying insurance, collecting payment, and offering financial counseling.

Viohl: We use both HFMA's MAP Keys and NAHAM Industry Standards Committee standards to help us determine the KPIs to watch. Currently, we report out to the revenue cycle committee and the finance board monthly on point-of-service collections; percentage of total patient cash collected as compared to point-ofservice patient cash; percentage of point-of-service collections as compared to adjusted net revenue; accuracy rates; pre-registration rates; first pass denial rates; and productivity. We offer monetary incentives tied to point-of-service collections to reward staff members for increasing collections and moving the effort up front.

Sett: Underpinning the KPI framework is information sharing, shared decision making, self-management, and partnerships-all key ingredients for enabling access, engaging patients, and getting paid for it. In addition to traditional KPIs, organizations should be collecting data related to price estimation, including how many price estimates are provided to the patient and how precise they are. To assess accuracy, organizations can compare the actual amount owed as determined by the payer with the amount of the estimate. By reviewing and monitoring this information, an organization can figure out whether it is reliably providing accurate estimate information in a timely fashion.

It is equally important to collect data about patient satisfaction. Being able to deliver financial information in such a way that preserves or even enhances patient satisfaction is becoming critical, especially as consumerism in health care increases. Soon, collecting patient satisfaction data that illustrate customers' appreciation or frustration with the financial process will become part and parcel of the patient access function.

PARTICIPANTS IN THE HFMA EXECUTIVE ROUNDTABLE

Richard Baney, MD, is chief medical informatics officer, Health First, Melbourne, Fla.

Jelfery Hurst is senior vice president and senior finance officer at Florida Hospital, Orlando, Fla.

Ajit Sett is vice president, revenue cycle solutions management-global, Allscripts, Philadelphia.

Melissa Viohl is director, patient access, Chesapeake Regional Healthcare, Chesapeake, Va.

Diane Watkins is vice president, revenue cycle, Saint Luke's Health System, Kansas City, Mo.

Sandra Wolfskill is director of healthcare finance policy, revenue cycle MAP, HFMA, Westchester, III.