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1 Automating Estimation of Patient Services Jonathan G. Wiik, MSHA, MBA Imaging Operations Manager Boulder Community Hospital Val Kraus, MBA Director of.

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Presentation on theme: "1 Automating Estimation of Patient Services Jonathan G. Wiik, MSHA, MBA Imaging Operations Manager Boulder Community Hospital Val Kraus, MBA Director of."— Presentation transcript:

1 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 2 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 patient’s 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 Estimation of Patient Services – Introduction

3 3 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 Estimation of Patient Services – Introduction The Advisory Board Company – HWORKS initiative

4 4 "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 Estimation of Patient Services – Current Trends AFP PHOTO/Saul LOEB

5 5 Session Objectives: 1.Discussion of trends in current Health Care market 2.Identify best practices to maximize collection efforts 3.Understand components of Estimating Pre- Service 4.Streamline scheduling and reception workflows 5.Outline training for front-line staff Estimation of Patient Services – Objectives

6 6 Estimation of Patient Services Current Trends

7 7 Estimation of Patient Services – Current Trends Percentage of Non-elderly Adult Workers Without Health Insurance, 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 Other research shows that tens of millions more Americans go without health coverage for shorter periods of time. Source: Employee Benefit Research Institute estimates from the Current Population Survey, March Supplements.

8 8 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 Total = million 47.4 Million Uninsured! Estimation of Patient Services – Current Trends

9 *2006 are actual data from the 2006 National Health Expenditure Accounts; are projected data from the 2006 National Health Expenditure Accounts. Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at (see Projected; NHE Historical and projections, , file nhe zip) and (see Historical; NHE summary including share of GDP, CY ; file nhegdp06.zip). NHE as a % of GDP: Dollars in Billions $4.3T

10 10 What are a BILLION or TRILLION Dollars?!! $ 1,000,000,000,000……”12” 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 Estimation of Patient Services – Current Trends

11 11 Declared bankruptcy Borrowed money from relatives Unable to pay for basic necessities like food, heat, or housing Used up all or most of savings Percent who say each of the following happened to them/their family member as a result of the financial cost of dealing with cancer… Ever uninsured 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) Estimation of Patient Services – Current Trends

12 12 Financial Burden of Medical Bills by Insurance Status, 2005 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. Percent of adults (age 19-64) reporting in past 12 months Estimation of Patient Services – Current Trends

13 13 Estimation of Patient Services – Current Trends Bureau of Economic Analyis - Personal Consumption Expenditures by Major Type of Product and Expenditure Medical care includes all expenses, including premiums, prescriptions, and out-of-pocket costs ** Other includes food other than groceries, alcohol, tobacco, luxury items, etc.

14 14 Estimation of Patient Services – Current Trends

15 15 Average annual premium for family of four in ?…. 1.National Coalition on Health Care Medical News Today (Coverted to 2008 using 10% inflation rate) Estimation of Patient Services – Current Trends $16,000 Average annual health care costs for family of four 2 ?…. $3,300 Average out-of-pocket costs for family of four (incl. Premium above) 2 ?…. $6,075

16 16 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 Estimation of Patient Services – Current Trends

17 17 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, Source: Kaiser Family Foundation/Health Research and Educational Trust. Estimation of Patient Services – Current Trends

18 18 Distribution of Deductibles for Employee-Only PPO Coverage, Source: Kaiser Family Foundation/Health Research and Educational Trust. Estimation of Patient Services – Current Trends

19 19 Distribution of Health Plan Enrollment for Covered Workers, by Plan Type, * Distribution is statistically different from the previous year shown (p<.05). No statistical tests were conducted for years prior to No statistical tests are conducted between 2005 and 2006 due to the addition of HDHP/SO as a new plan type in Note: Information was not obtained for POS plans in 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, ; KPMG Survey of Employer-Sponsored Health Benefits, 1993, 1996; The Health Insurance Association of America (HIAA), * * * * POS COLLECTIONS – Current Trends

20 20 Estimation of Patient Services Industry Best Practices

21 21 Estimation of Patient Services – Best Practices OUR JOURNEY…

22 22 Estimation of Patient Services – Best Practices

23 23 Estimation of Patient Services – Best Practices CURRENTLY: ~25% Collection Rate or 1.2% of Gross A/R

24 24 DO THE MATH!: Annual self pay losses versus savings in up- front collection: Estimation of Patient Services – Best Practices - Point of Service Collections, Techniques that Work, HFMA, Sandra Wolfskill Would you like to lose “$3.5M” OR “$2.0M” this year ???

25 25 Have clear intentions… Patients First, Collections Second 1 Treat ALL patients equitably, with dignity, with respect, and with compassion 2 Serve the Urgent and Emergent needs of everyone, regardless of their ability to pay 2 Assist patients who cannot pay for their part of the care they receive 2 Provide resources, NOT restrictions Make it an EXPECTATION Estimation of Patient Services – Best Practices 1. Point of Service Collections, Techniques that Work, HFMA, Sandra Wolfskill 2. Patient Friendly Billing Project, February 2005 Report

26 26 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 Estimation of Patient Services - Best Practices Overwhelming The Bad Debt Crisis - HWORKS Patient Friendly Billing Project, February 2005 Report

27 27 Identify and address the “barriers”:  We do not know what to collect?!  I’m not asking people for money?!  This is against our policy?!  You have never collected this from me before?!  Public Relations and Communications  Insignificant Dollars Estimation of Patient Services – Best Practices - Point of Service Collections, Techniques that Work, HFMA, Sandra Wolfskill

28 28 Estimation of Patient Services Components and Tools

29 29 Components of a Successful POS Collection Program: 1.Metrics (Data) 2.Executive-Level Support 3.Active Participation at All Levels 4.Policy, Procedure, Protocol and Scope 5.Patient Education Estimation of Patient Services – Components and Tools

30 30 1.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) Estimation of Patient Services – Components and Tools

31 31 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?) Estimation of Patient Services - Components and Tools

32 32 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? Estimation of Patient Services – Components and Tools

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

34 34 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 Estimation of Patient Services – Components and Tools

35 35 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 Estimation of Patient Services – Components and Tools

36 36 3. Active Participation at All Levels Administration and Management Billing Financial Counselors Clinical Personnel Other Areas Estimation of Patient Services – Components and Tools

37 37 Letters/Communication do not hurt….. Estimation of Patient Services - Components and Tools

38 38 3.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!!! Estimation of Patient Services – Components and Tools

39 39 “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 Estimation of Patient Services – Components and Tools

40 40 Estimation of Patient Services – Components and Tools

41 41 Estimation of Patient Services – Components and Tools

42 42 3.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 Estimation of Patient Services – Components and Tools

43 43 When is the question posed? At Physician’s 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… Estimation of Patient Services – Components and Tools

44 44 $ Estimation of Patient Services – Components and Tools

45 45 What’s 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 “C”’s: Confident Competent Compassionate Collaborative Estimation of Patient Services – Components and Tools

46 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 47 How much should I ask for?? –Remember the Bull’s Eye 1.Self-Pay 2.Indigent Copay 3.Known Insurance Patient Portion 4.Unknown Insurance Patient Portion Estimation of Patient Services – Components and Tools

48 48 Strategies to Determine Amounts: 1.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” Estimation of Patient Services – Components and Tools

49 49 Strategies to Determine Amounts: 2.Indigent Amounts Program Copay, Coinsurance, Deductibles Sliding scale to Federal Poverty Level (FPL) Estimation of Patient Services – Components and Tools

50 50 Strategies to Determine Amounts: 3.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 Estimation of Patient Services – Components and Tools

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

52 52 Strategies to Determine Amounts: 4.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 Estimation of Patient Services – Components and Tools

53 53 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 ~ per month, or approximately $100K+ in downstream revenue per month! Estimation of Patient Services – Components and Tools

54 54 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 Estimation of Patient Services – Components and Tools

55 55 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 Estimation of Patient Services – Components and Tools

56 56 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 Estimation of Patient Services – Components and Tools

57 57 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 Estimation of Patient Services – Components and Tools

58 58 Estimation of Patient Services – Components and Tools

59 59 Estimation of Patient Services – Components and Tools

60 60 Estimation of Patient Services Streamlining Workflows

61 61 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 Estimation of Patient Services – Streamling Workflows

62 62 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 Estimation of Patient Services – Streamling Workflows

63 63 Estimation of Patient Services – Streamling Workflows

64 64 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 Estimation of Patient Services – Streamlining Workflows

65 65 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) Estimation of Patient Services – Streamlining workflows

66 66 Estimation of Patient Services – Streamling Workflows

67 67 Estimation of Patient Services – Streamlining workflows

68 68 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 Estimation of Patient Services – Streamlining workflows

69 69 Estimation of Patient Services – Streamlining workflows

70 70 Estimation of Patient Services – Streamlining workflows

71 71 Estimation of Patient Services TRAINING FRONT LINE STAFF

72 72 Be empathetic not sympathetic –understand patient’s situation but pursue reasonable payment options with the patient Put yourself in the patient’s shoes –how would you want the situation explained, presented and handled? We must be sincere when empathizing with the patient Estimation of Patient Services – Training Overwhelming The Bad Debt Crisis - HWORKS

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

74 74 “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” Estimation of Patient Services – Training

75 75 “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. Estimation of Patient Services – Training

76 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 77 POS COLLECTIONS – Training

78 78 Estimation of Patient Services Conclusion

79 79 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 Estimation of Patient Services – Closing Thoughts

80 80 Develop a Strategy and Collection Mechanism that is: Easily deployed Elegant and simple Flexible by role and patient type Supported by management Scalable Estimation of Patient Services – Closing Thoughts

81 81 Have clear direction and momentum: 1.Have a meeting  At an early stage, ensure to include the people who are going to ask people for their money 2.Assemble a team 3.Build from existing workflows and add to them 4.Develop the “plan” 5.Test the workflows and track your results 6.Discuss Challenges and Celebrate Successes 7.Lead by example 8.Do not ever give up Estimation of Patient Services - Closing Thoughts

82 82 Questions? Estimation of Patient Services - Closing Thoughts THANK YOU Jonathan G. Wiik, MSHA, MBA Imaging Operations Manager Boulder Community Hospital (303) Val Kraus, MBA Director of Admissions and Case Management Boulder Community Hospital (303)


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