Operationalizing New Transparency Requirements

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46th Annual Educational Conference
Exhibition Patient Access   The First Connection
to a Lasting Impression   September 23, 2014
Operationalizing New Transparency Requirements
Katherine H. Murphy, FHAM, CHAM VP Revenue Cycle
Consulting, Passport/Experian Health 
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What Patients Want

• Designing Access is the Most Important Initiative
  You Can Undertake
• Expertise from Y-O-U!
• They do not want to work hard for Access or
  Information
• (If you make me work hard to do business with
  you I will go somewhere else)
• They want to be
• W-E-L-L
• Paul Roemer, VP Clinovations/Pale Rhino
  Consulting

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Transparency - Defined

• Generally implies openness, communication, and
  accountability. Transparency is operating in such
  a way that it is easy for others to see what
  actions are performed.
• The perceived quality of intentionally shared
  information from a sender".
• Infusion of greater disclosure, clarity, and
  accuracy into their communications with
  stakeholders

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• Can we make a complicated process
  simple?

Doc, What is Healthcare Transparency?
I think we need to schedule another appointment
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Todays Lesson

• Transparency Overviews
• Best Practice
• Industry Best Practice recommendations
• How to follow the recommendation
• Provider Journey
• Provider success story The start up current
  state
• Transparency future state
• Transparency Gone Wild! (Going the Extra Mile)
• Technology
• Patient Engagement
• How to drill down estimates and be closer to the
  truth!

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The Way We WERE
SoLola,what did you say a dial tone was for?
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The Patient Balance Death Spiral
PROJECTED 732
Breakdown of U.S. Healthcare Consumer
Responsibility U.S. billions, estimates
420
515
450
-- CONSUMER TO PROVIDER --
265
-- CONSUMER TO PROVIDER --
250
312
200
250
-- CONSUMER TO PAYER --
-- CONSUMER TO PAYER --
2005
2007
2015
Source 2007 2009 McKinsey analysis
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If only Price Transparency was this easy!
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I know everyone will be excited about new ways
not to get paid
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Transparency can occur whenever there is
communication between any two of

• Insurer
• Provider hospital/physician/Patient Access
  Patient
• Primary Care Physician
• Specialist
• Ancillary testing facility
• Post Acute Care
• Nursing Home
• Home Health
• Family Caregiver
• Pharmacy

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Today Transparency across the continuum! (not
related to any one episode)
New Paradigm Pop Health Mgmt
Old Paradigm episode of care

• Office Visit
• SchedulingTesting
• Admission/Reg
• Discharge
• Billingfor svc you provided
• Payment
• Bill me

• Connected to EMRs/ACOs
• Confirm appt / Pt Arrival/ Results
• PreService Clearance prior
• Phys office specialists Others
• Billingcombination of providers
• Bundled Payments
• Pay me

• .

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Moving from Volume to Value Whats
Different? Degree of Transparency!
From To
Fee for Service Payment Risk and/or Incentives for Keeping Patients Healthy. P4P (Pay for Performance), Shared Savings, Capitation
Care Not Coordinated Between Providers Providers Managing Continuum of Care. Right Care at the Right Place/Time. Care Coordination, Transitions of Care leveraging community resources
No Shared Patient Information Electronic Health Records enable information Sharing. Health Information Exchange
Doctors Wait for Sick People to Show Up Predictive modeling, Proactive Monitoring and Outreach. Telemedicine, Patient Centered Medical Home, Home visits
Patients Wait for Providers to Tell Them What to Do Patients Actively Engaged in Improving and Managing their Health. Personal Health Records, Home Monitoring Devices, Patient Engagement/Liability estimates
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So it shouldnt be a surprise that

• Notice to Patients Required for Outpatient
  Facility Fees
• Posted 24 Apr 2014 1136 AM PDT (Effective Oct.
  2014)
• The Connecticut House of Representatives
  responded on Wednesday to medical billing
  concerns patients expressed over undisclosed and
  unexpected facility fees by unanimously passing a
  bill that requires notice. Many patients
  expressed that the additional charges were a
  surprise when they received their bill. The
  legislation now moves to the state Senate for a
  vote. The charges, often referred to as
  "facility fees" are charged to patients by
  medical offices that are owned by hospitals for
  outpatient care. These fees are separate from
  doctor fees. Facility fees range from several
  hundred to thousands of dollars.The bill to
  require notice to patients about fees
  possible extra charges for outpatient care at
  medical offices owned by hospitals. The bill
  specifically requires that patients
  with scheduled appointments at medical offices
  where facility fees are charged receive notice
  about the fees in plain language before they
  receive treatments scheduled so long as the
  appointment is scheduled at least 10 days in
  advance. If the exact nature of the services or
  insurance coverage is unknown the patients would
  be provided with an estimate based on typical
  charges at the facility. Notice for patients
  receiving emergency care would need to be
  delivered as soon as practicable after the
  patient is stabilized. The bill does not impact
  the offices' ability to charge facility fees.
  Other provisions in the bill are include
  requirements that the office prominently displays
  that the facility is connected to a hospital,
  what hospital the office is affiliated with, and
  states that the patient may incur higher charges
  than if they were treated at a facility that
  isn't hospital-based.

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Massachusetts Chapter 224

• The law aims to control health care cost growth
  through a number of mechanisms, including the
  creation of new commissions and agencies to
  monitor and enforce the health care cost growth
  benchmark, wide adoption of alternative payment
  methodologies, increased price transparency,
  investments in wellness and prevention, an
  expanded primary care workforce, a focus on
  health resource planning, and further support for
  health information technology

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New BusinesseSinvestors are drawn to the
concept of price transparency, with shares
rising 139 percent on its first day of trading.

• Castlight is helping patients select the best
  price, and quality service. Are you ready?
• If youre not offering competitive prices and
  high quality outcomes employers and patients may
  start taking their business elsewhere. Wall
  Street appears to have casted their vote in favor
  of patient consumerism.

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Canary Infection Transparency

• Using the breath biomarker, we can pick up the
  body getting ready to fight infection ... even
  before the patient is showing signs,

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SharePractice - New way to rate treatment?

• Yelp for Doctors? over 5,000 health care
  providers using the app

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TapCloud
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What are we tasked with?

• And How do we accomplish

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Enterprise Transparency Provision of care

• Provider organizations will have clear policies
  on how to interact with patients with prior
  balances choosing to have elective or
  non-elective procedures. They will also have
  clear definitions for elective and non-elective
  procedures. These policies will be made available
  to the public.
• Brochures, Website, all documents
• Patients do not speak ABN, MSP, elective, In from
  Out!
• Lasix vs Furosemide

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Best Practices for Transparency

• Have defined processes for all patient types
• EMR OPT INPT Pre
• Discussion with Participants - not to disrupt
  workflow
• Patient Share Responsibility / Estimate /
  Navigation Counselor
• When Pre/Post Service, Emtala, Walk-ins
• Include Financial Screening along with Estimation
• Use of consumer data
• Toll Free number / Business Cards
• Appropriate Discussion Settings Script
• Pre Point - change in discharge process (fast
  pass?)

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The Best Payment Promise
Providers must

• Know who is in front of them. I.D. your patient
  Keep patient SAFE STOP RETURN Mail
• Define the medical language in CONSUMER language
• Have the correct insurance and benefit
  information.
• Tell patients what they will owe at the time of
  service.
• Enroll for Financial Assistance before rendering
  service.
• Extend hospital charity to those who qualify.
• Securely accept payment upfront for smaller
  balances.
• Extend payment terms and fundraising options for
  larger balances.

Every patient leaves knowing what they owe how
their services will be paid for! Excellence in
Patient Financial Triage includes determining the
Patients Preferred method for future
Communications!
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Who, Where, When? How easy is this for You?

• Prior Balance Discussion
• Balances across their continuum of care
• Payment plans tailored to successful collection
• Summary of Care Document
• Annual Training of Registration MSP,
  Collections, Payer Skills, Industry trends
  updates

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Measurement/communication

• Collections / accuracy
• Consumer satisfaction Surveys / real time
• Host Focus Groups
• Define Medical and Legal terms and provide access
  to them See handout
• Access success Reduction in Dups, return mail
  patient complaints, cancellations, no-shows
• Increase patient satisfaction scores,
  collections, employee satisfaction, positive
  internal relationships

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Pushing the Right Buttons at the right time!
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Negotiation Skill Training!

• Display Confidence!
• Be sensitive to the situation (emotional
  intelligence)
• Be aware of cultural differences
• Be humane, respectful and honest
• Determine what leverage you have
• Be realistic understand the strategy and policy
• Hire with these traits in mind

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Lisa Tozier St Josephs Story
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Provider overview

• Faith Based organization
• Bangor Maine, Population 33,000
• St Joseph Hospital/Covenant Health System
• Licensed for 112 beds
• Self pay portions increased volume
• Transparency collection new concept to
  patients
• Delicacy in rolling out the changes and keeping
  within the mission

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Patient Access/Revenue Integrity Manager

• Manage the day to day operations for a Patient
  Access staff of 30
• Responsible for pre-reg, pre-cert, face to face
  reg and the ED
• Manage the day to day operations for a
  Reimbursement staff of 3
• Responsible for managing charging throughout the
  hospital
• Responsible for managing RAC, MIC, ADR and 3rd
  party audits
• Liaison between the revenue cycle departments
• Lead our Revenue Integrity Team
• Spend 2 hours a week working with Patient
  Accounts solving issues
• Spend 2 hours a week working with IS to ensure
  our revenue cycle computer systems are running
  correctly.
• Lead implementation coordinator for all revenue
  cycle software
• Maintain security for revenue cycle software
  programs
• Responsible for the overall maintenance of the
  hospitals chargemaster
• Responsible for the expanded proration file

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Benefits offered

• Patient discounts from Providers
• Financial Counseling Services
• Card give to patient for Counseling hours
• Establishing a Physical Space and staffing in the
  ED (certified counselor for HIX)
• Key Factor Physical Space

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Centralized Decentralized oversight

• Challenges
• Training staff 2 day with pre-reg staff and
  time with education trainers
• ipad swipes / kiosks (where, which patients)
• Outcome More Transparency shorter throughput

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Communication - Liaison

• Role connectivity between rev cycle, ancillary
  and I.T. departments to make process improvements
• Automated process developed allows for Patient
  Access PFS transparency.
• Dedicated price estimation line and dedicated
  Financial Counseling line.
• Keep it Simple - allow for Patient Engagement
  via patient portal, smartphones etc

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Patient Responsibility Deposit Matrix Patient Responsibility Deposit Matrix Patient Responsibility Deposit Matrix Patient Responsibility Deposit Matrix Patient Responsibility Deposit Matrix Patient Responsibility Deposit Matrix
Department SJH employees and their family with Aetna through the hospital Patient Liability with Insurance or deductible from Passport or use amount below Medicare Patients with no secondary Self Pay WE DO NOT COLLECT FROM THE FOLLOWING PEOPLE
Inpatient 150 (if admitted through ED there is no charge) 150.00 NONE 500.00 MEDICARE PT WITH SECONDARY INS ALSO, WHEN MEDICARE IS THE SECONDARY INSURANCE
Emergency Department 150 copay If they dont have encourage payroll deduction 50.00 or copay per passport/card 10.00 200.00 PATIENTS WITH TWO OR MORE INSURANCES
Diabetes 10.00 10.00 10.00 100.00 MAINECARE PATIENTS WITH THE EXCEPTION OF THOSE THAT HAVE A CO-PAY
Nutrition 5.00 5.00 30.00 unless PT has dx of diabetes or renal disease then nothing 30.00 VA PATIENTS
Cardiology 10.00 10.00 10.00 90.00 WORKER'S COMP PATIENTS
Cardiac Cath 50.00 50.00 50.00 500.00 THIRD PARY LIABILITIES
ENDO (excludes colonscopies) 50.00 50.00 50.00 500.00 MVA'S
Outpatient Surgery 50.00 50.00 50.00 500.00 SCREENING MAMMOGRAMS
Pain Clinic 50.00 50.00 50.00 500.00 COLONOSCOPY PATIENTS
RBCC Diagnositics 25.00 25.00 10.00 200.00  
RBCC Bone density 10.00 10.00 10.00 70.00  
X-RAY 15.00 15.00 10.00 150.00  
CT, MRI, NUC, US, Sleep Lab, EEG 20.00 20.00 10.00 200.00  
Wound Clinic 20.00 20.00 10.00 100.00  
Infusion Clinic 5.00 5.00 10.00 50.00  
Hyperbaric 20.00 20.00 50.00 250.00

REMEMBER TO SMILE WHEN YOU SAY HOW WOULD YOU PREFER TO PAY FOR THAT TODAY REMEMBER TO SMILE WHEN YOU SAY HOW WOULD YOU PREFER TO PAY FOR THAT TODAY REMEMBER TO SMILE WHEN YOU SAY HOW WOULD YOU PREFER TO PAY FOR THAT TODAY REMEMBER TO SMILE WHEN YOU SAY HOW WOULD YOU PREFER TO PAY FOR THAT TODAY REMEMBER TO SMILE WHEN YOU SAY HOW WOULD YOU PREFER TO PAY FOR THAT TODAY
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Tackling Pricing Transparency

• CDM
• Historical Claims Data
• Complex Contract terms
• Manipulating pricing/co-morbidities
• Correct Insurance plan codes
• Rich Eligibility Data(Web, COB, HIX)
• Carve outs
• Ability to Pay
• Propensity to pay
• Collection process
• Payment plan creation
• Portal payments
• Ability to explain calculations

OUCH!
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1 Support from Internal resources

• ED and ancillary staff
• Revenue Cycle Departments
• Senior Management on board
• I.T.!
• Working to budget much needed resources
• Provider owner physician practices entities
• All staff physicians
• Their Office staff
• Marketing
• Educating consumers and supporting the vision is
  everyones job.

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Quality Management its whats upfront that
counts!

• Without quality data you cannot be transparent
  with any sense of accuracy
• Scrub accounts upfront
• Auto scripting corrections means less rekeying
  and less chance for error.
• Snapshots of electronic trx and info kept for
  audit trail
• Reports! Communicate Success!

Ya Gotta Be a Team Player
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Goals for Transparency implementation

• ONE Integrated platform Touchless processing!
  Lisa joined Exp/PP
• Work queues
• Address verification USPS and Validation
• Q.A.
• Eligibility Verification
• Scripting address eligibility
  corrections/carrier codes
• Medical Necessity
• Automated Pre-Authorizations
• Patient Liability Estimator
• Payment Processing
• Patient Portal results tracking/reporting
• Patient Kiosks m devices (Pt check-in to
  streamline experience)
• 2015 Financial Screening, Automated Charity
  apps
• Automated Physician Orders legible/screened/
  kick off!
• PreClaim scrubber and new claims processing
  solution
• New statements to better communicate bill,
  programs, even coupons!

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Future state

• Kiosks in all areas
• Scrubbing tool integrated with PFS
• Patient Portal for test results/appts and
  financial and clinical communications
• Automated PreAuth
• Work closely with Provider owned practices to
  move processes even farther to the front of the
  patient experience
• Physician liaison role to assist with the
  physician office relationships
• Automated phone calls to encourage pre-processing

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Vendor Selection
Customer Support
vendor
vendor
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COB SMART Wow!
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Include/Exclude?(Out of Pocket Options)
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Drilling Deeper into pricing
Combined Estimates

• Use Historical Claims Data
• Use CPT ICD codes
• Cross walk CPT to ICD
• Combine Hospital Physician liabilities
• Consider specific physician and location
• Establish high, average, low pricing
• Adjust specific line items
• Access readiness for ICD10 in automated tool

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Ill splane our silver burger plan
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(No Transcript)
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Eligibility HIX Response
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How can you? deny me? today?

• Grace Period claim denied? Claim paid?
• Collect from patient refund later?
• If the deductible hasnt been met cant you
  collect payment anyway? It is not covered right?
• If the patient pays the premiumdoes this payment
  automatically trigger a payment to the hospital?
• Will the hospital have to track and monitor
  denials to rebill?
• How must administrative cost is there?

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how do you make this possible?
Benefit data Contract Data
Financial Triage PIV
Accurate Data Denial Prevention
Skills Patient Satisfaction
CHANGE
Cashiering Tools
Payment Estimate
Through Technology!
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(No Transcript)
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Transparency Gone Wild!
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Sometimes Transparency is well
Opague

• Disclaimer verbiage
• Communicate typical variances up front
• Additional amount due vs. refund

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Why Estimates have transparency limitations

• The user selected the wrong procedure
• The wrong insurance code was selected and not
  fixed before the estimate was run
• A procedure was added on after the estimate
• Not all of the same surgeries will be the same
• Dealing with the unknown
• Co-morbidities..
• Chargemaster updates
• Contract updates
• Benefits not always there
• Co-insurance-moving target

GUESStimate
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Guesstimatron maGIC
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Transparency Navigator
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EstimatRON Cliff Notes
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Why Patients Cannot Easily Do Estimates?
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Consumer Facing Estimates
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Wildly Optimizing Begins at the very Beginning!

• Key Components (A-U-T-O-M-A-T-I-O-N)
• 1. Screen who should not be targeted for
  collections. Screen for bankruptcy, deceased,
  Medicaid Commercial eligibility and charity
  eligibility.
• 2. Segment to prioritize inventory and produce
  optimal collection and treatment strategies.
• 3. Route assign accounts to the most appropriate
  role pre/post

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Optimization

• 4. Performance Management Real-time dashboards
  and to support and drive business decisions.
• 5. Collaboration, Consultation and Analytics
  identify best practice collection strategies on
  going, evaluate reports for opportunities and
  anoint someone to oversee champion process.

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END GOAL
Healthy Happy Consumers
A healthy Provider revenue cycle
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What OTHER kinds of Wild?

• Telemedicine
• Gamification applied to healthcare engagement
  (Lets play a game)
• Change your process to meet the needs for
  customers of all ages and tech savviness.
• Hospitals compete for patients by developing
  their expertise in niche markets. This could just
  be quality customer service, consumer friendly
  processes, and confidence in experiencing the
  latest technology in place right at the start.
• Servant Leader Management Style

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Try new things! Collaborate with your business
partners to manage the new models
Passport Health a Part of Experian
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Be User FRIENDLY Intuitive.Show healthcare
consumers the love!
WowI can do this!
CHAM
Transparency
500,000 known, verified fraud records
Meaningful use More than 50 percent of all
unique patients online access to their health
information. Precisely I.D. your patients and
enroll in your Patient Portal!
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Education / NAHAM/Affiliates

• Ham Egg Breakfast
• The Chicken is invested
• The Pig is committed!
• Achieving Success comes at a price

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Patient Access
Congratulations and THANK YOU for another
G--R-E-A-T CAHAM conference!
Katherine H. Murphy, FHAM, CHAM, VP Revenue Cycle
Consulting, Passport-a part of Experian