Automating Estimation of Patient Services

1
Automating Estimation of Patient Services

• Jonathan G. Wiik, MSHA, MBA
• Imaging Operations Manager
• Boulder Community Hospital

Val Kraus, MBA Director of Admissions Case
Management Boulder Community Hospital
2

Estimation of Patient Services Introduction
The overall cost to collect is typically reported
between 2 and 3 percent Front-end processes are
important especially in this era of
increasingly high co-payments and
consumer-directed health plans. . the more time
that passes following the patients discharge,
the cost to collect on that account continues to
go up while the chance of actually collecting
payment goes down. Therefore, any payment that
can be collected early in the patient encounter
is more valuable in the long term.
Understanding your true costs to collect, HFMA,
JAN 2006
3
Estimation of Patient Services Introduction
Why Should the Patients Pay in Advance?

• Patients need to be educated and understands
  their financial obligations for the care they are
  receiving
• Eliminate discharge delays
• Eliminate worry about how to cover patient-pay
  portion
• Maintain or establish good credit record
• Patients earn piece of mind knowing their
  obligations have been met
• Avoid future collection headaches

The Advisory Board Company HWORKS initiative
4
Estimation of Patient Services Current Trends

• "The immediate goal is to make sure there are
  more people on private insurance plans.
• I mean, people have access to health care in
  America..after all, you just go to an emergency
  room.
• - President George W. Bush

AFP PHOTO/Saul LOEB
5
Estimation of Patient Services Objectives

• Session Objectives
• Discussion of trends in current Health Care
  market
• Identify best practices to maximize collection
  efforts
• Understand components of Estimating Pre-Service
• Streamline scheduling and reception workflows
• Outline training for front-line staff

6
Estimation of Patient Services

• Current Trends

7
Estimation of Patient Services Current Trends
The problem of the uninsured is continuing to
grow. The federal government estimates that
nearly 45 million individuals lacked health
insurance coverage of any kind during 2005. Other
research shows that tens of millions more
Americans go without health coverage for shorter
periods of time.
Percentage of Non-elderly Adult Workers Without
Health Insurance, 1987-2005
Source Employee Benefit Research Institute
estimates from the Current Population Survey,
March 1988-2006 Supplements.
8
Estimation of Patient Services Current Trends
47.4 Million Uninsured!
2006 Total 296.1 million
NOTE Includes those over age 65. Medicaid/Other
Public includes Medicaid, SCHIP, other state
programs, and military-related coverage. Those
enrolled in both Medicare and Medicaid (1.8 of
total population) are shown as Medicare
beneficiaries.


SOURCE Kaiser Commission on Medicaid and the
Uninsured/Urban Institute analysis of March 2007
CPS.
9
Estimation of Patient Services Current Trends
10
Estimation of Patient Services Current Trends

• What are a BILLION or TRILLION Dollars?!!
• 1,000,000,000,00012 zeros..or..
  one-thousand-billion
• One Million dollars stacks up 500 feet - as tall
  as the big pyramid in Egypt
• One Billion dollars is 10 times higher than Mt.
  Everest
• One Trillion dollars is 1/4 of the way to the
  Moon or 60,000 miles.
• It would take someone more than 30 years to
  count aloud to one Billion
• If you had gone into business on the day Jesus
  was born 2013 years ago, and your business
  lost a million dollars a day, day in and day out,
  365 days a year, it would have taken you until
  October 2737 to lose just ONE Trillion dollars

www.buelahman.wordpress.com/2008/05/06/what-does-a
-trillion-look-like www.jimloy.com/math/trillion.h
tm www.scoroncocolo.com/debt.html www.ehd.org/scie
nce_technology_largenumbers.php
11
Estimation of Patient Services Current Trends
Percent who say each of the following happened to
them/their family member as a result of the
financial cost of dealing with cancer
Used up all or most of savings
Borrowed money from relatives
Unable to pay for basic necessities like food,
heat, or housing
Ever uninsured
Declared bankruptcy
Always insured
Source USA Today/Kaiser Family
Foundation/Harvard School of Public Health
National Survey of Households Affected by Cancer
(conducted Aug 1-Sept 14, 2006)
12
Financial Burden of Medical Bills by Insurance
Status, 2005
Estimation of Patient Services Current Trends
Percent of adults (age 19-64) reporting in past
12 months
NOTE Insured includes those with public or
private insurance coverage. SOURCE Kaiser
Commission on Medicaid and the Uninsured analysis
of the Kaiser Low-Income Coverage and Access
Survey 2005 National All-Income Sample.
13
Estimation of Patient Services Current Trends

• Medical care includes all expenses, including
  premiums, prescriptions, and out-of-pocket costs
• Other includes food other than groceries,
  alcohol, tobacco, luxury items, etc.

Bureau of Economic Analyis - Personal Consumption
Expenditures by Major Type of Product and
Expenditure www.bea.gov/national/nipaweb/nipa_und
erlying/TableView.asp?SelectedTable19FirstYear2
007LastYear2008FreqQtr
14
Estimation of Patient Services Current Trends
15
Estimation of Patient Services Current Trends

• Average annual premium for family of four in
  20081?.

3,300
Average out-of-pocket costs for family of four
(incl. Premium above)2?.
6,075
Average annual health care costs for family of
four2?.
16,000

• National Coalition on Health Care 2008.
  www.nchc.org/facts/cost.shtml
• Medical News Today (Coverted to 2008 using 10
  inflation rate)
• www.medicalnewstoday.com/articles

16
Estimation of Patient Services Current Trends

• Having a job, even a full-time job, does not
  guarantee access to health insurance.

Uninsured Non-elderly Population by Work Status
of Family Head, 2005
Source Employee Benefit Research Institute
estimates from the March Current Population
Survey, 2006 Supplement
17
Estimation of Patient Services Current Trends

• Many workers are paying higher co-payments for
  physician visits in HMOs.

Percentage of Covered Workers Facing Various HMO
Co-payment Amounts for Physician Office Visits,
1996-2006
Source Kaiser Family Foundation/Health Research
and Educational Trust.
18
Estimation of Patient Services Current Trends

Distribution of Deductibles for Employee-Only PPO
Coverage, 2000-2006                             
                                               
Source Kaiser Family Foundation/Health Research
and Educational Trust.
19
Distribution of Health Plan Enrollment for
Covered Workers, by Plan Type, 1988-2007
POS COLLECTIONS Current Trends
Distribution is statistically different from
the previous year shown (plt.05). No statistical
tests were conducted for years prior to 1999. No
statistical tests are conducted between 2005 and
2006 due to the addition of HDHP/SO as a new plan
type in 2006. Note Information was not obtained
for POS plans in 1988. A portion of the change
in plan type enrollment for 2005 is likely
attributable to incorporating more recent Census
Bureau estimates of the number of state and local
government workers and removing federal workers
from the weights. See the Survey Design and
Methods Section from the 2005 Kaiser/HRET Survey
of Employer-Sponsored Health Benefits for
additional information. Source Kaiser/HRET
Survey of Employer-Sponsored Health Benefits,
1999-2007 KPMG Survey of Employer-Sponsored
Health Benefits, 1993, 1996 The Health Insurance
Association of America (HIAA), 1988.
20
Estimation of Patient Services

• Industry Best Practices

21
Estimation of Patient Services Best Practices
OUR JOURNEY
22
Estimation of Patient Services Best Practices
23
Estimation of Patient Services Best Practices
CURRENTLY 25 Collection Rate or 1.2 of
Gross A/R
24
Estimation of Patient Services Best Practices

• DO THE MATH!
• Annual self pay losses versus savings in up-front
  collection

• Would you like to lose 3.5M OR
• 2.0M
• this year ???

- Point of Service Collections, Techniques that
Work, HFMA, Sandra Wolfskill
25
Estimation of Patient Services Best Practices

• Have clear intentions
• Patients First, Collections Second1
• Treat ALL patients equitably, with dignity, with
  respect, and with compassion2
• Serve the Urgent and Emergent needs of everyone,
  regardless of their ability to pay2
• Assist patients who cannot pay for their part of
  the care they receive2
• Provide resources, NOT restrictions
• Make it an EXPECTATION

1. Point of Service Collections, Techniques that
Work, HFMA, Sandra Wolfskill 2. Patient Friendly
Billing Project, February 2005 Report
26
Estimation of Patient Services - Best Practices

• Best Practices of Top-Performing Facilities
• Adopt guiding principles and communicate the
  message
• Set the expectations, and establish
  accountability
• Update the mission, job descriptions, policies,
  and procedures
• Couple patients with the best funding mechanism
  available
• best could be charity care

Overwhelming The Bad Debt Crisis - HWORKS Patient
Friendly Billing Project, February 2005 Report
27
Estimation of Patient Services Best Practices

• Identify and address the barriers
• We do not know what to collect?!
• Im not asking people for money?!
• This is against our policy?!
• You have never collected this from me before?!
• Public Relations and Communications
• Insignificant Dollars

- Point of Service Collections, Techniques that
Work, HFMA, Sandra Wolfskill
28
Estimation of Patient Services

• Components and Tools

29
Estimation of Patient Services Components and
Tools

• Components of a Successful POS Collection
  Program
• Metrics (Data)
• Executive-Level Support
• Active Participation at All Levels
• Policy, Procedure, Protocol and Scope
• Patient Education

30
Estimation of Patient Services Components and
Tools

• Metrics - DATA
• High Level
• Billed Revenue
• Reimbursement
• Up-front (POS) Collections (if any)
• Bad Debt Write-offs ()
• Detail
• Payer Mix including Self-Pay (uninsured)
• Account Aging and Costs (A/R, Collections agency,
  etc.)
• Patient Mix (Outpatient, Inpatient, ED)
• Number of Scheduled Patients and Walk-ins
• Modality Mix (CT, MRI, XRAY, ULTRASOUND)
• Access Points and Volume at each area
  (Scheduling/Reception/Intake/Admissions)

31
Estimation of Patient Services - Components and
Tools

• Why so much data?!
• Get a Baseline (What can we track?)
• Identify Priorities (Why is this important?)
• Focus efforts (Who will be impacted?)
• Establish Goals (When can we do this?)
• Determine Needs (How can we do this?)

32
Estimation of Patient Services Components and
Tools

• KNOW your numbers.
• How much should an uninsured person pay?
• What do we collect if it is not on the card?
• What do we do if data is not available?
• How do (or can) we estimate allowable?
• What can we (or can we not) estimate in advance?

33
Estimation of Patient Services Components and
Tools
Drill down to the core.
34
Estimation of Patient Services Components and
Tools

• 2. Executive-Level Support
• Bottom-up, top-down, sideways, and up-side-down,
  the organizational CULTURE must live, breathe,
  and act consistently
• Every person, from the Radiologist to the
  Receptionist, from the Office Manger to the
  patient, must clearly understand the project and
  its rationale
• Services should not be reduced in a POS
  Collections Program they should be ENHANCED

35
Estimation of Patient Services Components and
Tools

• 2. Executive-Level Support (cont.)
• Typical POS Collections Team
• Executive - VP/CFO, Owner, Office Manager
• Director / Site Manager (s)
• Billing and Contracting
• Admissions / Scheduling / Reception
• Others?
• If multi-site/functional areas, leads from each
  access point should be represented
• Should end up with 6-8 key personnel involved
  in patient and billing flow
• This group should have a philosophical,
  business-decision discussion concerning
  boundaries PRIOR to any implementation

36
Estimation of Patient Services Components and
Tools

• 3. Active Participation at All Levels
• Administration and Management
• Billing
• Financial Counselors
• Clinical Personnel
• Other Areas

37
Estimation of Patient Services - Components and
Tools

• Letters/Communication do not hurt..

38
Estimation of Patient Services Components and
Tools

• Policy, Procedure, Protocol and Scope
• Three Doors for funding their care
• Insurance
• No Insurance (self-pay)
• Other Funding Mechanism (be specific)
• ONE (AND ONLY ONE) OF THE ABOVE MUST
• BE ELECTED BY THE PATIENT PRIOR TO
• RENDERING SERVICES NO EXCEPTIONS!!!

39
Estimation of Patient Services Components and
Tools

• DOOR will determine direction and conversation
  we take with the patient
• Collection Advisory List
• Medicare/Medicaid
• Third Party Liability (Work comp, MVA,
  Litigation)
• Agreements
• Patient Types
• ED, STAT, URGENT, SAME DAY ADD-ONS
• Procedure changes
• Oncology, Mammography, DEXA
• Indigent, Homeless, Out-of-network

40
Estimation of Patient Services Components and
Tools
41
Estimation of Patient Services Components and
Tools
42
Estimation of Patient Services Components and
Tools

• Policy, Procedure, Protocol and Scope(cont.)
• Be VERY clear on the following
• who is asked
• when the question is posed
• what is said
• what happens when people refuse or get upset
• who is contacted for service recovery

43
Estimation of Patient Services Components and
Tools

• When is the question posed?
• At Physicians office?
• At Scheduling?
• At Reception?
• On the Table?
• Earlier and the more frequent, the better
• ELIMINATE SURPRISES
• What is said?
• Tailor the conversation to fit the situation

44
Estimation of Patient Services Components and
Tools
UNKNOWN INSURANCE BENEFITS
KNOWN INSURANCE BENEFITS
INDIGENT PROGRAMS
SELF - PAY

45
Estimation of Patient Services Components and
Tools

• Whats Realistic?
• Scripting is difficult and does not afford
  flexibility, however in some cases you must
  ensure consistency
• Key Phrases are best where possible
• The 4 Cs
• Confident
• Competent
• Compassionate
• Collaborative

46
Estimation of Patient Services Components and
Tools

• EXAMPLES
• Key Phrases
• All of our patients are expected to.
• Do you know what your payment is today?
• We have several options available for payment,
  our best is?
• We typically do ______ when patients ______.
• Most patients elect this option as it.

47
Estimation of Patient Services Components and
Tools

• How much should I ask for??
• Remember the Bulls Eye
• Self-Pay
• Indigent Copay
• Known Insurance Patient Portion
• Unknown Insurance Patient Portion

48
Estimation of Patient Services Components and
Tools

• Strategies to Determine Amounts
• Self-pay
• Take average net-deduction-in-revenue (NDR) and
  add 5-10 for administrative savings
• For example, if block of business has an NDR of
  25, make the self-pay amount 35
• Take charge master and reduce billed amounts by
  35 to establish Prompt Pay Fee Schedule by
  Category and/or line-item CPT
• ALL PATIENTS WHO PAY AT TIME OF SERVICE WHO DO
  NOT HAVE INSURANCE ARE ELGIBLE FOR THE PROMPT PAY
  DISCOUNT. PAYMENT MUST BE MADE IN FULL AT TIME
  OF SERVICE TO BE ELIGIBLE

49
Estimation of Patient Services Components and
Tools

• Strategies to Determine Amounts
• Indigent Amounts
• Program Copay, Coinsurance, Deductibles
• Sliding scale to Federal Poverty Level (FPL)

50
Estimation of Patient Services Components and
Tools

• Strategies to Determine Amounts
• KNOWN insurance amounts
• Collect what is on the card
• Copays
• Coinsurance/Deductible
• Estimate allowable amount(s)
• BEWARE of the floating deductible
• Have patients bring in Benefits Screen
  Prints/EOBs
• Have patients or staff call insurance in advance
• ASK patient and collect that

51
Estimation of Patient Services Components and
Tools
DATA IS FICTIONAL NOT ACTUAL CHARGES
52
Estimation of Patient Services Components and
Tools

• Strategies to Determine Amounts
• UNKNOWN insurance amounts
• Consider benefits of collection versus downstream
  costs to refund
• Avoid over collecting
• Customer Service issues
• Refund Turn Around Time
• Inflated Results
• Carrier and Employer ripple effect
• Credit Card on File

53
Estimation of Patient Services Components and
Tools

• Strategies to Determine Amounts
• Credit Card on File
• Store Credit Card Numbers for subsequent billing
• Line of Credit
• Compare to when you check into Hotel and they
  take a card for incidentals
• Several vendors offer a software solution that
  integrates/replaces existing credit card
  terminals
• BCH Imaging alone generates 600-700 per month,
  or approximately 100K in downstream revenue per
  month!

54
Estimation of Patient Services Components and
Tools

• Other considerations with Amounts
• Distribution and communication of amounts is
  critical
• Paper or Plastic?
• Do you have hard copy price sheets, or do you
  have software
• Version Control
• Usability/Math
• Accuracy

55
Estimation of Patient Services Components and
Tools

• Other considerations with Amounts
• Estimators
• Homegrown
• Spreadsheet, Database, Calculators, Abacus, Paper
• PROs Cheap and Easy
• CONs Time investment, Maintenance, Inaccurate
• Proprietary
• Real-time estimate and/or eligibility
• Configured to managed care contracts
• PROs Accurate, Fast, Professional
• CONs Initially can be expensive with
• hardware/software, interface/integration
  concerns

56
Estimation of Patient Services Components and
Tools

• Other considerations with Amounts
• Estimators (Continued)
• But we NEED this fancy new thingy?!!!
• Prove it
• Pilot/Trial in focused area to demonstrate value
• ROI
• Proformas
• Customer Service
• Huge Opportunities
• several vendors
• buyers market currently
• ROI is typically a matter of months

57
Estimation of Patient Services Components and
Tools

• Estimators (Continued)
• Determine Risk at front end from Eligibility,
  Auth, Benefit/OOP, and propensity to pay
• Couple with Credit Scoring to establish
  eligibility to other funding mechanisms
• Pre-qualify scheduled appointments
• Streamline estimation and eligibility checks

58
Estimation of Patient Services Components and
Tools
59
Estimation of Patient Services Components and
Tools
60
Estimation of Patient Services

• Streamlining Workflows

61
Estimation of Patient Services Streamling
Workflows

• Implementation Suggestions
• Test the workflow
• Role Play
• Roll out in Phases
• Focus efforts on simple items first
• low-hanging fruit, e.g. uninsured/self-pay

62
Estimation of Patient Services Streamling
Workflows

• Keep it simple..
• It is an expectation of your job to ask for
  patient portions
• Ask the simple question Do you know your
  amount to pay today?
• Provide Options, NOT ultimatums
• Start small, use paper, then expand to
  system-wide integration

63
Estimation of Patient Services Streamling
Workflows
64
Estimation of Patient Services Streamlining
Workflows

• LOOK BEFORE YOUR LEAP
• Know the amounts (even if a estimates) before you
  ask people, to ask patients, for it
• Know how you are going to handle and process the
  money
• Know how to handle customer service issues and
  complaints
• Know how to defend the mission of the POS
  Collections Effort
• Know how to adjust the process quickly

65
Estimation of Patient Services Streamlining
workflows

• Workflow Development
• Develop POLICY to support the PROCEDURE within
  the SCOPE of the project
• Determine
• When (Specific Steps)
• Who (Collection Advisory)
• Why (Doors and Bulls eye)
• What (how much )
• How (Scripting/Key Phrases)

66
Estimation of Patient Services Streamling
Workflows
67
Estimation of Patient Services Streamlining
workflows
68
Estimation of Patient Services Streamlining
workflows
Be prepared to handle the following scenarios
with patients

• They may not have their wallet
• They may not have their ins card
• Their may not have cash on hand
• They may not have credit cards
• Their deductible may be too high

69
Estimation of Patient Services Streamlining
workflows
70
Estimation of Patient Services Streamlining
workflows
71
Estimation of Patient Services

• TRAINING FRONT LINE STAFF

72
Estimation of Patient Services Training

• Be empathetic not sympathetic
• understand patients situation but pursue
  reasonable payment options with the patient
• Put yourself in the patients shoes
• how would you want the situation explained,
  presented and handled?
• We must be sincere when empathizing with the
  patient

Overwhelming The Bad Debt Crisis - HWORKS
73
How Do You Request For Payment In Advance?
Estimation of Patient Services Training

• Registrars must choose their words carefully and
  be respectful, yet be direct with the patient
• Registrars need to be aware of their tone of
  voice when speaking with the patient
• Be firm about hospital policy and reassure the
  patient that paying in advance is for their
  benefit

Overwhelming The Bad Debt Crisis - HWORKS
74
Estimation of Patient Services Training

• The goal of the BCH POS Collections Program is
  not to collect money. Our goal is to educate
  patients as to the costs of their care, and help
  them navigate these costs
• Boulder Community Hospital strives to help
  patients understand their health care costs. In
  that effort, coverage is verified, costs are
  discussed, and payment arrangements are made - in
  advance. Through this, bad debt is reduced and
  the operations of our hospital remain financially
  viable to continually serve our community

75

Estimation of Patient Services Training
I never had to pay at time of service before.
REGISTRAR RESPONSE
I understand that you may have not been asked
before. Since you were here last, we have made
changes to our processes that no longer allow us
to delay collecting payments. Also, there are
many advantages of paying up-front. Foremost,
you know the costs of your health care upfront,
and we can process your payment using a variety
of options available to you right now. How would
you like to pay today? We accept check, cash,
credit cards.
76
Estimation of Patient Services Training

• Incentive Plans
• Health Care is moving to retail, business-like
  atmosphere
• Should not pay people to their jobs, it is an
  expectation
• Award successes and good performance
• Set awards at roughly 3-6 of salary
• Incentives work, but are risky
• Ensure Longevity of plan before launching
• Large Policy and procedure

77
POS COLLECTIONS Training
78
Estimation of Patient Services

• Conclusion

79
Estimation of Patient Services Closing Thoughts

• In Summary
• Critically analyze market trends and evaluate
  best practices
• Adopt what would work well in your organization
• Identify the components and scale the project to
  the resources you have available
• Train, retrain, and adapt the workflows
• Educate your coworkers, customers, and community

80
Estimation of Patient Services Closing Thoughts

• Develop a Strategy and Collection Mechanism that
  is
• Easily deployed
• Elegant and simple
• Flexible by role and patient type
• Supported by management
• Scalable

81
Estimation of Patient Services - Closing Thoughts

• Have clear direction and momentum
• Have a meeting
• At an early stage, ensure to include the people
  who are going to ask people for their money
• Assemble a team
• Build from existing workflows and add to them
• Develop the plan
• Test the workflows and track your results
• Discuss Challenges and Celebrate Successes
• Lead by example
• Do not ever give up

82
Estimation of Patient Services - Closing Thoughts
THANK YOU

• Questions?

Jonathan G. Wiik, MSHA, MBA Imaging Operations
Manager Boulder Community Hospital (303)
440-2049 jwiik_at_bch.org
Val Kraus, MBA Director of Admissions and Case
Management Boulder Community Hospital (303)
440-2124 vkraus_at_bch.org