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Western PA HFMA & Three Rivers AAHAM, Winter Education Conference “If only we had known sooner the patient couldn’t pay that much,” AKA: “Woulda, Shoulda,

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Presentation on theme: "Western PA HFMA & Three Rivers AAHAM, Winter Education Conference “If only we had known sooner the patient couldn’t pay that much,” AKA: “Woulda, Shoulda,"— Presentation transcript:

1 Western PA HFMA & Three Rivers AAHAM, Winter Education Conference “If only we had known sooner the patient couldn’t pay that much,” AKA: “Woulda, Shoulda, Coulda” Larry Estes TransUnion Healthcare

2 Then Next Now Today Where we are. What is changing around us? What if we don’t make a change? Where we’ve been.

3 How did 2013 go? Exceed hospital’s patient access and revenue cycle KPI goals? Exceed National Benchmarks/Best Practices? Sitting on extra money? Making CFO happy?

4 Clinical diagnosis Determine symptoms via questions Collect data History Test results Deliver treatment plan Wrong treatment? Financial diagnosis Determine symptoms via questions & data ID, Insurance Eligibility, Estimation History Financial Information (Bad Debt?) Deliver financial plan Wrong treatment? Lost time = patient gets worse before getting better! Lost Time = lost revenue/increased expenses (or - hospital gets worse…)

5 Challenging how healthcare operates Rising patient out- of-pocket costs Reduced reimbursements Stagnant revenue growth Increasing bad debt Consumer-directed health plans now more popular than HMOs In conjunction with shifting plan designs, lower reimbursement rates Patients are responsible for greater portion of medical costs = increase in bad debt Patients are forgoing lucrative elective procedures

6 © 2010 TransUnion LLC All Rights Reserved6 Critical Business Issues: Pre-Service ProcessCritical Business Issues Point-of-Service Collections Financial Clearance – WHY? Determining the patient’s ability-to-pay and if they qualify for financial assistance is a key driver for increased collections at the POS Self-pay balances continue to rise Traditional collection rates are stagnant or decreasing Macro economic factors (unemployment, etc.) are increasing the need for more effective POS collections Difficulty determining which patients have the ability, capacity and propensity to pay Financial Counseling Charity and Financial Aid Screening – WHY? Matching uninsured or underinsured patients to the appropriate funding sources is a critical revenue source Numerous programs and requirements Tedious manual processes to qualify and enroll patients into appropriate programs Lack of patient involvement to provide supporting financial information

7 © 2010 TransUnion LLC All Rights Reserved7 Critical Business Issues: Post-Service ProcessCritical Business Issues Medicaid Re-Verification Identify Self-Pay Accounts that were Enrolled in Medicaid at the Date of Service – WHY? Recover reimbursements from self-pay accounts that were previously thought to be uninsured Difficulty identifying all Medicaid coverage at registration Lost reimbursements from accounts that will most likely roll to bad debt Identify opportunities for future billing based upon current coverage Charity Determination Discern true charity care from bad debt – WHY? Address IRS 990 Schedule H reporting requirements Accurately report and track charitable giving Lack of patient involvement to provide supporting financial information Inability to identify patients truly in need – resulting in wasted collection efforts Could/Should be Pre-Service, too!

8 statements before a patient begins to pay the hospital 1 Source: McKinsey Quarterly, June 2007, “Overhauling the US healthcare payment system” Nick A. LeCuyer and Shubham Singhal % of an insured patients’ balance becomes bad debt 1 % of an uninsured patients’ balance becomes bad debt 1 = $60 Billion in bad debt/year

9 Guess What? Annual Out-of-Pocket for Families Covered by Employer- Sponsored Insurance Covered Workers with Deductible >$1,000 = $4,316 1 = 34% 1 1 Source: The 2012 Employer Health Benefits Survey, the Kaiser Family Foundation and the Health Research and Educational Trust (HRET), September 2012.

10 Challenges in 2014 – Déjà Vu all over again Rising patient deductibles – at even faster pace Higher co-pays More patients than ever –Newly Insured: “I owe money? But I have insurance!” –Always Been Insured: “I owe money? But I have insurance!” Insured? Not insured? –ACA Premiums Paid? 90 day grace period? (This should be fun.) Lower reimbursements Bad Debt vs. Charity Care

11 With ACA HIE’s (A-OK?) Deductible* Patient Co- Insurance Patient Out of Pocket Bronze 1$4,375 20%$6,350 Bronze 2$3,475 40%$6,350 Silver 1$2,050 20%$6,350 Silver 2$650 40%$6,350 1 Source: Kaiser Family Foundation, April 2012, “Patient Cost-Sharing Under the Affordable Care Act” *Deductible doubled for family 1 !

12 Woulda, Shoulda, Coulda “A bird in the hand is worth two in the bush.” – John Ray's A Hand-book of Proverbs, 1670 “Too soon old and too late smart.” –Pennsylvania Dutch saying “Hindsight is always 20/20.” –Virtually every politician ever elected. “If I had only known….” –Former Employee “If only I knew then what I know now.” –Anyone who ever made past age 30. “D’oh!” –Homer Simpson

13 How will you react? Insanity: doing the same thing over and over again and expecting different results. - Albert Einstein

14 I know! Let’s Have a Meeting! “We can tweak our process to make it work!” “Let’s come up with some ideas for next year.” Goes something like this….

15 One Thing Leads to Another “If You Give a Mouse a Cookie…”

16

17 © 2010 TransUnion LLC All Rights Reserved17© 2010 TransUnion LLC All Rights Reserved17 ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? Are they them? –Are they giving me an accurate name, address, phone number, SSN and date of birth? Insurance? How much will it be? Can they pay POS? Will I (can I?) collect on the back- end? Eligible for financial assistance? External Data

18 © 2010 TransUnion LLC All Rights Reserved18© 2010 TransUnion LLC All Rights Reserved18 External Data = Financial Diagnosis = Options FPL < 100% with no insurance Potential charity care or Medicaid Strong ability to pay with nominal copay Collect payment at time of service Identity issues Potential fraud Borderline ability to pay with large deductible Consider for financing solutions

19 1. One-stop shops ▪Ask questions  Who owns the financial data you’re buying?  Who maintains, updates software, loads payer contracts, history?  Where do they get eligibility info? ▪Big companies usually will, but remind niche companies to accept responsibility  One contract, One contact 2. Best in Breed ▪How well do they play together? ▪Seamless data transmission can happen among better vendors, but may mean separate contracts and contacts. 3. Considered an Investment, not Expense!

20 Accept Appointment Physician EMR or Portal 3 Text ? ID and Address Verification Eligibilty Estimation Insurance Authorization Medical Necessity Charity Assessment Automation Patient Responsibility Credit Report/ Financial Analysis Full Patient Financial Discussion Self- Service Kiosk e-cashiering/ Payment Plan Admitted/ Procedure Discharge HIS Integration Reporting/Dashboard Work List Manager / Rules Engine / Data Audit / Exception Manager

21 The Key? Build Your Process to Stay Ahead of the Game… The Chocolate Factory

22 Pieces and Data needed to know your Patient and “treat” efficiently Registration Accuracy Insurance Eligibility Financial Analysis Charity Assessment Payment Estimation Payment Processing Patient Loans Bad Debt Risk Oh, and - Stay Ahead of the Game!

23 Larry Estes Regional Sales Executive TransUnion Healthcare (717)


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