The Patient-Centric Revenue Cycle (is good for business)
A big chunk of common sense is missing in the discussion
surrounding American healthcare. It
could be that the right people are not doing most of the talking and decision-making.
Talking heads around the subject of how to fix healthcare in the United States
clutter up the conversation to the point that most Americans are left just hoping that - somehow - everything
will shake out and settle in so they can go about their lives and confront all
the other worries they have in life. Many well-intentioned people have
attempted to make incremental changes or tweaks. Healthcare providers are
spending nearly 65% of their budgets on administrative costs and personnel to
keep up – which means that less than 40% of healthcare provider resources can
be dedicated to innovation. Perhaps it’s
time to think in a radically different way.
The question that none of the surveys are asking is, “How
does the cost of healthcare services, the information you received prior to
receiving services, and the care you received from the Finance/Billing Department
after your care affect your feelings about your overall experience?” Yet, every American family has at least one
story of frustration with healthcare that has roots in costs, billing, and
insurance. According to a 2012 survey1 done by Mark Blankenship of Opinion
Access for the American Health Care Association, more than 50% of Americans had
a negative or very negative impression of for-profit healthcare systems, and
less than 15% felt very positive about for-profit healthcare systems.
Surprisingly, less than 1/3 of respondents felt positively about not-for-profit
healthcare systems, too. Everyone is
purporting their expert opinions and no one – NO ONE – is listening to the
angst of Americans as patients and caregivers. The fact of the matter is that a
patient’s perception of their healthcare is materially related to their overall
perception of healthcare services. More importantly, patient concerns and/or
frustration with healthcare billing, insurance , co-pays, deductibles, and
non-covered services are reflected in their overall opinions of the hospital,
their doctors, and the surveys they fill out.
Americans don’t really care about the details of the ACA,
AHCA, or whatever acronym is applied.
What Americans, and all of the other people in the world who count on
being able to find quality care and innovative technology in U.S. hospitals,
care about is to have a means to affordable,
quality healthcare.
Make no mistake. Americans are passionate about how decisions and regulations made in Washington
affect them personally. Who they see, however, as frustrating them are the people
in front of them. Even when patients are
very pleased with their medical care and the hospital facilities, their first
impressions, when they sit down to register, and their last impressions, when they receive
their bill, color their opinions about
the healthcare organization overall.
Health is personal. Bills are personal. When a patient has a reason to seek treatment
for a health condition, their doctors and nurses are part of their team;
champions and experts who comfort and cure.
Then the bills start rolling in and patients feel that suddenly they are
alone and the hospital is in an adversarial relationship with them. As industry regulations and insurance
restrictions have pressured financial
positions, healthcare organizations have spent a great deal of time and effort
to educate clinical staff about the revenue cycle. It is important that we also
teach “bedside manner” to the Finance Department.
Medicare changed healthcare delivery and reimbursement in
1965. Medicaid changed healthcare delivery and reimbursement more expansively.
Medicare part D changed healthcare delivery and reimbursement yet again; taxing Medicare budgets substantially – as well
as providing fertile ground for pharmaceutical and durable medical equipment costs
to rise. The ACA fundamentally changed the relationship between physicians and
patients, shifted control of healthcare decision-making, and added new layers
of administrative burden to healthcare providers. Good intentions all, but from 1965 forward
healthcare providers have struggled to keep up with administrative costs and
responsibilities.
In more than twenty years of working in healthcare, I’ve had
the opportunity to talk to hundreds of patients, physicians, and healthcare
workers. The revenue cycle matters! It
took years for hospitals to understand that the revenue cycle was important to
the fiscal health of the organization. It seems that the fact that the revenue
cycle – or at least the impact of the revenue cycle – is just as important to
patients.
Patients need to be able to make informed decisions about
their healthcare, and they also need to be cared for after services are
received and the bills start rolling in. In order to provide patients with
realistic cost estimates for patient out-of-pocket expenses prior to care, healthcare
providers need to be able to access in real-time, according to their individual
contracts with insurance carriers, exactly what the patient’s benefits are for
the proposed treatment plan. To underscore that statement; that means insurance carriers need to provide current
balances for patient deductibles met and accurate assessments of coverage
according to the patient’s benefits for ALL services – not just the
most-utilized or the procedures paid at the highest rates. For example, cancer
treatment benefits are not available on insurance websites.
It would be awesome if insurance carriers made it possible
for patients to estimate their own benefits according to their plan for the
prescribed treatment ahead of their arrival for treatment. Preferably, patients should be able to access
an estimate for their out-of-pocket expenses through their insurance carrier
website and/ or by telephone using current customary charges from the healthcare
provider’s website and reimbursement rates based on their insurance carrier’s
contract with their specific healthcare provider. Many healthcare providers allow patients to
estimate their costs based on the provider’s usual charges for a particular
service, but the patient still has to then review their coverage and any claims
they have already submitted in the current year and make additional
calculations. Even the savviest of patients can get lost in all of that.
·
Insurance companies already have access to this
information, broken down by individual providers, and even by individual
patient, according to claims received
and reimbursements paid.
·
Insurance plans also have access to current
records on how much deductible patients have individually met at the time of
estimate,
·
as well as contract information related to the
patient’s specific responsibilities for co-pays, maximum out-of-pocket, etc.
·
The patient’s insurance plan sees all claims
from all healthcare providers, and is therefore at an advantage to be able to relay
accurate information to patients.
·
Insurance plans need to improve the
knowledge-base, and in most cases improve access to their beneficiaries’ actual
contracts and benefits to their customer service front line, so that
communication with patients who request estimates of benefits via telephone or
have questions about their benefits receive substantive and accurate
information.
·
The relationship between a patient and their
insurance plan is between those two entities. Insurance companies are
responsible to their beneficiaries to pay claims in the manner agreed by contract.
·
Healthcare providers have a solemn responsibility
to the patient to explain fully to the patient the proposed treatments, side effects
and expected outcomes. They are also responsible to be accountable for
questions patients have about why the cost of their care is what it is, and
what plans, programs, grants, or arrangements the healthcare organization can
make available to assist patients with out-of-pocket expenses.
In defaulting all explanations to patients concerning what
their insurance will and won’t pay for to the healthcare provider, the
insurance companies quite deftly abdicate responsibility and patients see the
healthcare provider as both their hope for care and their adversary for the
cost from the beginning.
The second half of caring for our patients throughout the revenue cycle
again belongs jointly to insurance companies and healthcare providers; but
falls most heavily to the finance teams of the healthcare providers. Healthcare providers need to
·
Provide clear and easily navigable information for
patients to find average charges for procedures
·
Meet with patients one-on-one prior to all
elective procedures to establish payment plans and outline charges for services
·
Provide access and avenues to available
financial assistance; including grants, outside services, and Medicaid
applications
·
Establish policies and provide copies to
patients for expectations for payment and financial assistance
·
Train registrars, financial counselors, customer
service, and collectors in empathy and monitor for consistent behavior aligned
with organizational values
·
All Patient Access staff should be well-trained
in available assistance, financial policies, and escalation for special
circumstances and patient questions or concerns
·
Provide patient statements that are clear and
easy to understand in layman’s terms
·
Reach out personally to patients who have
outstanding bills in a friendly way to reinforce the relationship, verify that
the patient is aware of pending due dates and still able to meet them, and ask
if they have any questions – and reliably connect the patient with their
physician’s office if medical questions come up.
Once treatment has been delivered to the
patient and the bills start rolling in, patients should already have clarity
concerning their financial obligations and an established relationship with at
least one (and preferably more than one) person in the finance department who is
assigned to follow their account and respond to questions. Patients should be able to pull an itemized
statement of their charges on line or easily request them through a direct
phone line.
A third point, though perhaps not more than wishful thinking
today, would be to streamline the insurance billing process altogether. The United States is the only healthcare system
in the world that uses ICD-10 coding for purposes of healthcare
reimbursement. What would happen if patients
received, as they have been requesting for at least as long as I can remember,
a single statement for all services rendered – or in the case of chronic
conditions one statement each month – instead of separate statements from
individual providers for individual services? CMS already requires monthly
claims for Medicare patients, and
coordinated care by multiple providers is already a fact. To further streamline
patient billing, (and I fully expect to hear “pooh-pooh” from many voices – but
just consider and humor me here) it should also be entirely possible to collect
into one billing statement all care a patient receives regardless of patient status. All physician orders and charges are already
time-stamped, so in theory a patient who arrived through the ED, went to
surgery, subsequently admitted as an
in-patient post-op would still be able
to receive one bill for an entire episode of care.
In the end, the patient has to be allowed to return to the center
of the equation for American healthcare. Regulations , ever-decreasing reimbursements,
exploding demand, and insurance interests have dominated the conversation and
driven the focus of healthcare providers for a generation. The revenue cycle matters to healthcare
organizations for their fiscal health, but more importantly, the revenue cycle
matters to patients because to them it’s personal.
1 Mark Blankenship, Opinion Access, Survey
Results submitted to American Health Care Association,
