A flurry of stakeholder complaints around the "convener" requirement for good faith estimates (GFE) has put pressure on CMS to take action.
Several major health care industry groups have issued statements in recent days calling for CMS to make changes related to its convener requirement, which asks providers to create charge estimates for some patients that cover not only their own services but those of downstream providers, according to Part B News.
For example, the American Hospital Association (AHA) executive vice president Stacey Hughes asked CMS to extend its "enforcement discretion" on the convener requirement beyond next January 1.
"Due to the lack of currently available automated solutions, this process would require a significant manual effort by providers, which would undoubtedly result in the convening provider being unable to meet the short statutory timeframes for delivering good faith estimates to the patients and could also lead to inadvertent errors," Hughes wrote.
The American Medical Group Association (AMGA) also sent an open letter to CMS saying GFE requirements have resulted in significant challenges for providers to effectively schedule, coordinate, and deliver care.
AMGA members report completing more than 45,000 GFEs in a month and expect that number will increase, according to the association.
"The current GFE requirements impose additional stress to an already strained healthcare workforce," said AMGA president and CEO Jerry Penso. "CMS should reform the process so that the estimates provide the information patients need without creating new administrative obstacles for providers to overcome."
It’s unclear how many organizations have faced a significant impact from the convener requirement, but Darryl Drevna, AMGA’s senior director of regulatory affairs, says some AMGA members who are part of health systems have been hit hard. Some members have told Drevna their systems have generated 45,000 to 50,000 GFEs since the policy took effect January 1.
When it comes to the "convener" requirement, which is all tied to the No Surprises Act, experts predict CMS will bend on the requirement but is unlikely to remove it entirely, according to Part B News.
Experts and health care personnel seem to agree the convener job poses difficulties.
According to a survey from the Workgroup for Electronic Data Interchange (WEDI), formal advisors to HHS on health IT, 86% of respondents say it would be very difficult or difficult for providers and facilities to determine who should be the convening provider or facility.
Some 83% of respondents supported delaying the requirement "until there is standardized data exchange process in place to communicate information between convening providers and co-providers/co-facilities."
Paul Johnson, the former Phoenix mayor who runs the care coordination company Redirect Health in Scottsdale, Arizona, told Part B News that his company also operates a clinic that has to follow policies that have stemmed from the No Surprises Act, and "from the clinic side these rules are really hard and we’re struggling to implement them."
However, Johnson also acknowledges that "from our customer's standpoint, balance billing and disclosure are high priority issues" and believes the convener requirement can be doable if all parties are cooperating.
As a care coordinator he routinely works with hospitals on billing for multi-provider service costs and finds that “when we work with hospitals around the country, we find a lot of them are very cooperative about helping us get a price and editing downstream costs,” Johnson says.
"Granted, a lot of others try to play games—they give us a price and send a balance bill to our customer." Johnson thinks for some hospitals this is still "a standard course of business... But [the No Surprises Act] is helping address that system issue."
Other experts point to additional issues that have to be squared away. "Groups within the provider community have been communicating both formally and informally with CMS about these requirements," David McLean, partner with Hall Booth Smith PC in Atlanta told Part B News.
"For example, take mental health providers. It’s very difficult to put together a GFE for their services because you’re looking at an open-ended term of illness and you can’t really create an upfront estimate," McLean said.
Drevna says the technical issue is a major part of the convener problem.
"There's no way to automate this process," he says. "Our EHRs don’t have the capability to transmit this sort of information or even communicate provider-to-provider when systems aren’t set up to share billing details provider-to-provider. They’re designed to work with payers."
Read more about this analysis and if experts see CMS relenting on this requirement on our sister publication Part B News.
More than half of hospitals evaluated in a recent JAMA study did not adhere to price transparency requirements, as researchers call for more scrutiny to ensure compliance.
The No Surprises Act, which became effective January 1, requires hospitals to post the prices for their most common procedures as well as a patient-friendly tool to help shop for 300 common services.
According to a recent study published by JAMA, out of the 5,239 hospital websites evaluated, roughly 51% of hospitals did not adhere to either price transparency requirement.
Almost 14% of hospitals studied had a machine-readable file but no shoppable display while 30% of hospitals had a shoppable display but not a machine-readable file, according to the study. It also found less than 6% of hospitals were compliant with both components of the mandate.
Researchers also found that hospitals located in moderately concentrated or highly concentrated healthcare markets were significantly less likely to be transparent with their prices. Concluding their findings, the researchers noted that greater scrutiny of organizations within these areas may be needed to ensure adherence to price transparency.
Other hospital characteristics such as total gross revenue, size, emergency service capabilities and ownership type were not associated with a facility's adherence to the mandate, they wrote.
The team acknowledged that their count of adherent hospitals could be an underestimate as some may have updated their websites within the study's three-month data collection window.
This study doesn't come as much of a surprise as earlier research shows similar results in the adherence to price transparency.
For example, a study published earlier this year by PatientRightsAdvocate.org showed that most organizations were not fully complying with the hospital price transparency rule.
The report assessed the compliance with the law by reviewing 1,000 U.S. hospitals out of the over 6,000 accredited hospitals in the country.
Of the 1,000 total hospitals reviewed in the study, only 14.3% were fully complying with the rule. The study also found that only 37.9% of the hospitals posted a sufficient amount of negotiated rates, but over half were not compliant in other criteria of the rule, such as rates by each insurer and named plan.
Some of the largest hospital systems in the country fell short in this study.
The Center for Disease Control and Prevention (CDC) released 1,176 new ICD-10-CM diagnosis codes for implementation on October 1.
A total of 1,176 new diagnosis codes were recently finalized within the fiscal year (FY) 2023 ICD-10-CM code update. The CDC also posted the FY 2023 coding guidelines along with the code update which will take effect October 1.
In addition to the 1,176 new codes, the update also includes 28 codes that had revisions to their descriptors, and 287 codes deemed invalid.
One example of a code description revision is in the diagnosis code for dementia in other diseases classified elsewhere without behavioral disturbance. The diagnosis code description for this diagnosis will be revised to “dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.”
As for the updated coding guidelines, a new guideline was added for the assignment of dementia which states that selection of the appropriate severity level (unspecified, mild, moderate, or severe) “requires the provider’s clinical judgment and codes should be assigned only on the basis of provider documentation unless otherwise instructed by the classification. If the documentation does not provide information about the severity of the dementia, assign the appropriate code for unspecified severity.”
The coding department is one of the most critical parts of the revenue cycle. Because coding occurs mid-cycle, it provides an opportunity to catch errors introduced earlier in the process, as well as preventing similar errors in the future.
Staying abreast of these regulatory coding updates is important for revenue cycle leaders as coding—and its completeness and accuracy—has a profound impact on an organization's bottom line.
Leaders at Intermountain Healthcare discuss their journey merging physician and CDI teams and implementing the use of AI to streamline its middle revenue cycle.
Strong CDI and physician collaboration directly contributes to the overall health of an organization's revenue cycle. With the growth of automation, data availability, and tracking, it is increasingly important for the middle revenue cycle to become a priority for healthcare organizations.
That's why Kearstin Jorgenson, operations director of physician advisor services, and Dr. Kory Anderson, medical director of physician advisor services, CDI, and quality, at Intermountain Healthcare worked to streamline their middle revenue cycle by bringing their physician and CDI teams together and implementing AI.
For Intermountain Healthcare, revenue integrity and revenue cycle optimization are the ultimate goals and building a united team within the middle revenue cycle focused on patient experience and safety produced high-quality results that aligned with high-quality care.
Finding and addressing the gaps
According to Jorgenson and Dr. Anderson, CDI and physician communication was a large gap in their revenue cycle. They would often reach out to the physician advisor department to ask for help to reach physicians, message items appropriately, and talk with them peer-to-peer.
Intermountain Healthcare was also dealing with archaic, manual processes and a lack of buy-in. This made it difficult to ensure the true clinical picture of the patient was captured and done in a way that allowed for accurate reporting on measures like case mix index, patient safety indicators, and risk of mortality scores.
This is when Jorgenson and Dr. Anderson knew they needed a partnership.
Individually the departments were strong, but they needed to work together to really improve their revenue cycle. At Intermountain Healthcare, CDI teams are the experts in documentation, opportunities, and trends, whereas the physicians have expertise in effectively communicating peer-to-peer.
When the CDI team began talks with hospital leadership about how best to bring the two areas of expertise together, it became apparent that having a physician leader in the CDI team would be beneficial.
The physician advisor department already had champions and educators, so it made sense to position them to be the frontline advocates with the CDI nurses on CDI work.
Meanwhile, Jorgenson and Dr. Anderson said there was an executive leadership change, and multiple departments (including the CDI and physician advocacy teams) came together under one umbrella: the office of patient experience.
Through all of this, the two teams were able to align their work in more meaningful ways. After transformational change and the new operational footprint was in place, Intermountain Healthcare focused on three areas critical to the success of this new collaboration:
Champions and advocates: Responsible for promoting the importance of the program, hosting regular meetings, and advocating for engagement in CDI workflows
Strategy: The Intermountain Healthcare team's strategy is built on three pillars
Their approach to engaging providers
The design of their CDI integration within the provider workflow
Their commitment to always bridging CDI and physician work to the patient
Data transparency: Focused on establishing key performance indicators with medical leaders, overseeing the dissemination of reports, and highlighting metric success to senior leaders
To help streamline even more, Intermountain Healthcare also turned to computer-assisted physician documentation powered by 3M AI, which provides best practice nudges to physicians during documentation, applies clinical reasoning across the patient encounter, and helps physicians get things right the first time, avoiding rework and associated administrative burden by the CDI team.
The benefits of added automation and of bringing the two teams together underneath the office of patient experience were vast, Jorgenson and Dr. Anderson said, as it puts the big picture emphasis on improving the patient experience and quality of care as opposed to solely looking through a financial lens.
With the two teams working together, it unites all the functions that contribute to the capture, management, and collection of patient service revenue.
Intermountain Healthcare says it is now able to effectively collaborate, which contributes to better coding and documentation capture, thus reducing the risk of noncompliance, optimizes payment, and minimizes the expense that comes with fixing problems later on.
"The loudest message for us is the patient," Jorgenson said. "We want to make sure we are doing the right thing for them, ensuring they receive safe, quality care and making sure we provide that care consistently."
Challenges and solutions
There were obstacles to undergoing such a large endeavor, Jorgenson and Dr. Anderson said. Getting engagement from physicians was one of the biggest challenges for the team—but there were solutions.
Once the two teams aligned, it was still tough to engage physicians, Dr. Anderson said. What made the difference was getting third-party benchmarking data on quality. Then the Intermountain Healthcare team wasn’t solely comparing themselves against other facilities or systems in the same area, but rather facilities and systems across the country.
"Seeing the data was eye-opening to our system leaders. Some of the data was very good, and other data was not so good. It led to the fact that we need to do well because this is what patients and other folks see about us as an organization and can use it to decide where they may or may not get their care," said Dr. Anderson.
Another challenge was that before the teams came together, they were dealing with manual workflows and processes that couldn’t support Intermountain Healthcare’s focus on quality and financial measures. While physicians and CDI teams are both invested in complete, accurate patient records, their workflows were often misaligned.
To make improvements and increase optimization, Intermountain Healthcare turned to AI.
When doing so, it was critical to intersect the new system with the physicians’ workflow in the EHR. The goal was to use AI to automatically nudge physicians about common document deficiencies up front. A change that would reduce rework and free the CDI team to focus on more complex quality reviews.
Following this change the results included:
The nudges proactively support physicians in addressing common documentation gaps before the note is saved
Physicians can rapidly address the nudges and gaps in real-time instead of having to dig for queries later
The AI generates a nudge when appropriate by continually applying clinical reasoning across the patient encounter
It brought together traditionally siloed physician and CDI workflows, enabling both teams to take advantage of the same clinical understanding
Intermountain Healthcare also redesigned the workflow for the new team through account prioritization and relying on AI to generate prioritized worklists focused on cases with the most opportunity for improvement. Since this change, quality indicators and second-level mortality reviews have become part of the standard workflow.
Uniting individual facilities within the healthcare system was also a challenge for the organization. Large healthcare systems may be united by a vision and a direction, but each facility has its own nuances and differences, and they aren’t all staffed the same.
Intermountain Healthcare found success by partnering with facilities on an individual basis to understand how they are best suited to own and drive the work and then tailor the approach from there.
Another challenge was hesitancy, said Jorgenson. Both the CDI and the physician advocacy teams have a lot of skilled, experienced staff, but when Intermountain Healthcare first aligned the two, Dr. Anderson and Jorgenson noticed that seasoned professionals were hesitant to admit when they didn’t know something. They didn't want to be seen as someone who didn’t have a depth of understanding.
They focused on that dynamic and worked to change it. When someone did ask a question or admitted that they didn’t know something, it was met with positive reinforcement.
"We’re stronger when we're able to rely on each other's expertise," Jorgenson said. "If you don't know something, that's fantastic. Bring it up."
Tips for other organizations
Center key performance indicators (KPI) on quality metrics
Dr. Anderson and Jorgenson have talked to numerous facilities around the country, and they see many aligning under a finance focus. Finance can be the loudest message sometimes, but what needs to resound is quality, they said.
Intermountain Healthcare focused on quality metrics that were directly impacted by clinical documentation, physician engagement, and education.
"We used to struggle to get an audience," Dr. Anderson said. "Now people are coming to us to talk about strategies and what they could do to improve those metrics."
Bring teams together in a way that still enables them to do their best work
For Intermountain Healthcare, the CDI nurses continue to focus on trends and identify what the team needs to learn. They collaborate with the physicians, and then the physicians go out and build relationships, look for common and shared understanding, and deliver educational presentations.
Bring education work in-house when possible
Intermountain Healthcare used to contract education out to vendors. Now the team does in-house training whenever possible.
Dr. Anderson and Jorgenson say they're getting better engagement with providers because educational sessions are happening between colleagues.
The person leading the session and those who attend see and work with each other in the hospital every day. This allows for more natural accountability and continuous improvements and adjustments because conversations can happen on the job and in the moment, they said.
Follow-through is also greater with in-house education. Intermountain Healthcare has set up quarterly meetings to connect on what’s going well, what isn’t going well, and how to close the gaps.
Seeing results
While it's still early in the initiative, Intermountain Healthcare has already achieved results from merging teams and implementing AI.
Intermountain Healthcare says CDI efficiency has increased similar to having hired 4.6 additional specialist RNs. The increase in efficiency has allowed the CDI team to focus on more complex quality and mortality reviews.
Intermountain Healthcare has also seen significant improvements in patient safety indicator trends and a decrease in patient safety indicators, a better case mix index, improved risk of mortality scores, and higher query response rates.
Substantial progress was also made in engaging physician groups, particularly hospitalists and intensivists, and physicians are now documenting some conditions on their own without being nudged, Dr. Anderson and Jorgenson said.
Intermountain Healthcare says all of this has helped them accurately represent the complex patients they take care of in a way they weren’t able to before.
"Moving from a financial focus to a quality focus gave us a platform for change," Jorgenson said.
What’s next
Intermountain Healthcare is working to finalize its computer-assisted physician documentation rollout to rural facilities within the system while also diversifying the provider nudges.
Quantification and optimization of evidence sheets, leveraging technology to better identify clinical cohorts for review, and continuing to think through more complex CDI opportunities are all part of Intermountain Healthcare’s future plans in optimizing its middle revenue cycle.
The procedure code update includes 331 new codes to be used for discharges occurring from October 1, 2022, through September 30, 2023.
The ICD-10-PCS update includes tabular updates for heart surgeries and digestive operations performed with laser interstitial thermal therapy. CMS also made updates to reporting procedures involving new technologies.
At the same time as the code update, CMS released the procedure coding guidelines, which include new guidelines for reporting procedures of certain extremities.
The coding department is one of the most critical parts of the revenue cycle. Because coding occurs mid-cycle, it provides an opportunity to catch errors introduced earlier in the process, as well as preventing similar errors in the future.
Staying abreast of these regulatory coding updates is important for revenue cycle leaders as coding—and its completeness and accuracy—has a profound impact on an organization's bottom line.
The American Medical Group Association (AMGA) raised concerns about the good faith estimate (GFE) process and how it is creating an administrative burden for medical groups.
In a letter to CMS, AMGA members said GFE requirements have resulted in significant challenges for providers to effectively schedule, coordinate, and deliver care.
AMGA members report completing more than 45,000 GFEs in a month and expect that number will increase, according to the association.
"The current GFE requirements impose additional stress to an already strained healthcare workforce," said AMGA president and CEO Jerry Penso. "CMS should reform the process so that the estimates provide the information patients need without creating new administrative obstacles for providers to overcome."
The AMGA says it applauds HHS' efforts to promote transparency but believes there is a misunderstanding as to the infrastructure needed to satisfy GFE requirements in a timely matter.
In the letter, AMGA members say their concerns stem from three key areas:
Unclear guidance: Guidelines issued to providers are either confusing or conflicting, and providers have raised questions about the circumstances necessitating the delivery of a GFE to a patient
Staffing constraints: AMGA members report that non-medical staff are required to allocate a significant number of hours to complete GFEs
Cost and infrastructure barriers: AMGA members report a significant expense associated with completing GFEs
In line with the cost and infrastructure barriers, the AGMA says there is currently no realistic way to complete GFEs electronically.
"Members are developing workflows and infrastructure to support GFEs, but doing so diverts scarce resources from other priorities, particularly during the ongoing public health emergency. This includes reassigning staff from other duties to complete GFEs," the letter says.
The AMGA recommends that CMS work with stakeholders to develop a process in which GFEs are beneficial for patients, while not causing additional administrative burdens to providers.
HealthLeaders' new series highlights five essential governing updates that cover every aspect of the revenue cycle that leaders need to know. Check back in each month for more regulatory updates.
The revenue cycle is complex, detailed, and always changing, so staying on top of regulatory updates and latest best practices requires revenue cycle leaders' constant attention in this ever-changing industry. In this revenue cycle regulatory roundup, there were an ample number of updates published by CMS and the OIG in May, including studies on prior authorization requests and patient harm.
Here are the five updates you need to know.
1. Even the OIG has prior authorizations on the mind.
The OIG published a reportregarding whether Medicare Advantage Organizations (MAO) are appropriately approving or denying services which require prior authorizations: What it found was not great and has even set off the American Hospital Association (AHA).
The OIG looked at a stratified random sample of 250 denials of prior authorization requests and 250 payment denials issued by 15 of the largest MAOs in June 2019.
It found that 13% of the prior authorization requests that the MAOs denied actually met Medicare coverage rules. The two common causes of those denials were MAOs using clinical criteria for medical necessity beyond what Medicare has in its coverage rules and MAOs stating that prior authorization requests did not have sufficient documentation to support approval when the OIG’s reviewers said the documentation provided was more than sufficient to support the request.
The OIG also found that 18% of the payment request denials met Medicare coverage rules and MAO billing rules. The OIG attributed most of these denials to human error and system processing error.
The OIG recommends CMS issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews, update its audit protocols to address issues identified in this report, and direct MAOs to take steps to identify and address vulnerabilities that can lead to manual review errors and system errors. CMS agreed with all recommendations.
Because of this, the AHA is calling on the Department of Justice (DOJ) to establish a task force to conduct investigations into health insurance companies that routinely deny patients access to care and payments to providers.
In a letter to acting assistant attorney general Brian Boynton, the AHA states that it is time for the DOJ to exercise its False Claims Act authority to penalize MAOs that restrict services to beneficiaries, citing this OIG report.
2. Patient safety for the Medicare population is in the spotlight.
The OIG published a report regarding adverse events in hospitals in October 2018. The report is a repeat of one that was published in 2010 that looked at patient harm in October 2008.
In this newer report, the OIG found that 25% of Medicare patients experienced patient harm during their hospital stays in October 2018.
Physician reviewers determined that 43% of these harm events could have been prevented if patients had been provided better care. Of the 25% of patients who experienced harm, 12% of patients experienced adverse events that led to longer hospital stays, permanent harm, life-saving intervention, or death. The other 13% of patients experienced types of harm that were temporary and required intervention but did not have longer-lasting effects. The most common types of harm events were related to medication (43%) and patient-care issues (23%).
The OIG noted that while HHS has taken steps in the past to improve patient safety in hospitals, it must do more. The OIG issued seven recommendations, three of which applied to CMS.
Those included recommendations that CMS update and broaden its lists of hospital-acquired conditions to capture common, preventable, and high-cost harm events; explore expanding the use of patient safety metrics in pilots and demonstrations for health care payment and service delivery; and develop and release interpretive guidance to surveyors for assessing hospital compliance with requirements to track and monitor patient harm.
3. Be on the lookout for potential hospital outpatient payment changes.
CMS published a transmittalregarding the July 2022 updates to the hospital outpatient prospective payment system. Updates include a new code for the over-the-counter COVID-19 test demonstration, four new procedures assigned to new technology ambulatory payment classifications, and more.
It’s important for revenue cycle leaders to keep an eye on the OPPS as it’s also tied to price transparency regulations. For example, in the 2022 OPPS final rule, CMS increased price transparency penalties.
4. The Joint Commission will continue to be the CMS’ hospital accreditation program of choice.
CMS published a final noticein the Federal Register to announce its decision to approve The Joint Commission for continued recognition as a national accrediting organization for hospitals that wish to participate in Medicare or Medicaid.
5. You may be off the hook from a full-scale emergency exercise.
CMS revised a memorandum to state survey agency directors regarding clarifications on testing exercise requirements in light of the COVID-19 public health emergency (PHE).
Due to the continued PHE and the number of facilities still operating under disaster/emergency conditions, CMS is exempting any inpatient or outpatient facility still operating under an activated emergency from the full-scale exercise requirement for specified 12-month cycles of testing exercises. Revisions add information for outpatient providers and revised the information on individual facility-based exercises and important reminders.
At the HealthLeaders Revenue Cycle Exchange, which was recently held in Louisville, Kentucky, revenue cycle leaders opened up about gaps they are seeing in their department.
Pre-registration difficulties were top of mind at the recent HealthLeaders Revenue Cycle Exchange. When asked to identify areas that see the biggest gaps in their revenue cycles, 68% of the leaders pointed the finger at pre-registration. Another area of difficulty is insurance follow-up, as 64% of attendees marked this as a gap in their operation.
Other concerns among this group of prominent VPs and directors include registration and utilization review, as 56% and 52% of leaders, respectively, flagged these areas as pain points within their organizations.
These trends aren’t surprising, as most of these sectors within the revenue cycle have been linked to staffing shortages and automation challenges.
For example, echoing the same gaps as leaders at the Revenue Cycle Exchange, a recent survey, which included responses from 400 healthcare financial leaders, ranked registrars, billing specialists, and patient follow-up staff as the most in-demand positions within the revenue cycle.
The American Hospital Association also recently declared its frustration with pre-registration and other front-end revenue cycle processes, not only due to staff shortages but also the lack of automation.
It’s no surprise that when asked what top trends they are focused on in the immediate future, most (83%) executives at the event cited automation and/or technology.
Other immediate areas of focus were data/analytics and improved financial performance with 58% and 66% of attendees choosing these areas, respectively.
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at our LinkedIn page.
To inquire about attending a HealthLeaders Exchange event, email us at exchange@healthleadersmedia.com.
The Office of Inspector General recently audited the Department of Veterans Affairs' (VA) EHR implementation and found problems with its current data migration, interface usage, and user access.
After a series of problems and delays in the VA's implementation of a new EHR modernization (EHRM) program, more issues have surfaced despite the departments’ efforts.
The EHRM program was created to connect and improve data exchange between the Department of Defense (DOD), the VA, and external health providers.
According to the audit, the goal of its implementation is to increase EHR interoperability and create the ability to exchange EHRs securely with other HIT systems without special effort on the part of the user.
The audit states that the DOD and VA did not take all needed actions for interoperability, however, possibly in part because the oversight committee (FERHM) had little active engagement in the program.
According to the audit, the office failed to:
Consistently migrate patient information to create a single, complete patient EHR
Develop interfaces from all medical devices so patient information will automatically upload to the system from those devices
Ensure that users were granted access to the software for only the information needed to perform their duties
The audit recommended the FERHM program director develop and implement plans to create interfaces for medical devices that will easily connect and transfer data to the new EHR platform, modify user roles to better limit patient information, migrate patient information after defining the type of healthcare information that constitutes a complete EHR, and more.
The patient financial experience is just as important to a hospital as a patient's clinical experience. Healthcare leaders share their thoughts on current billing challenges and solutions.
Editor's note:This article appears in the March 2023 edition of HealthLeaders magazine.
Revenue cycle leaders must pay attention to each aspect of an organization's revenue cycle to have a prospering organization. Although there is an individual argument for streamlining each segment of the cycle, when it comes to improving the patient financial experience, it's imperative to put the microscope on an organization's current billing process.
Chris Johnson, vice president of revenue cycle at Atrium Health, and Chris Cox, senior vice president of product, strategy, and operations at iVitaFi, recently spoke at the HealthLeaders Patient Financial Experience NOW Summit about challenges they are seeing in the industry when it comes to the billing process and proactive ways to solve these challenges.
"We often hear in the industry that the patient experience was great and everything was phenomenal, then the patient gets the bill and all of the sudden the perception of the services received can change which impacts the patient financial experience," Johnson said.
As Johnson said, this shows that improving the billing experience can drive up satisfaction scores and an overall positive patient experience for an organization. Cox added that the patient billing experience affects how the patient ultimately feels about their experience at that organization, regardless of how the clinical care went—so it's important to remedy when it comes to patient leakage.
"Providers lose, on average, between 10%–30% of revenue as a result of patient leakage, and that's hundreds of millions of dollars in losses per year," said Cox.
Examining the challenges
So where should organizations start when looking to improve this patient experience?
"There are quite a few challenges in the market today when it comes to a patient's billing experience," said Johnson. Narrowing down those challenges and working on perfecting them will ensure a positive patient financial experience.
When it comes to a patient's bill, it's common for certain populations to find the amount of information presented overwhelming.
"Healthcare billing continues to be a complex process especially since you have the provider, patient, and payer all involved," said Johnson. "Quite frankly, when some patients see an insurer's use of CPT and ICD-10-CM codes, it can be like a foreign language, and it can cause real confusion."
Another added component seen across the healthcare industry is that patient bills still tend to show gross charges for the service or services provided to a patient.
"While gross charges are not the actual amount paid by insurers or patients, we continue to use them for billing purposes across our industry. Providers often assume patients are not concerned about gross charges, but this may not be the case." Johnson said.
"When we send a patient an itemized bill and they see their gross charges for $100,000—all of the sudden they are interested in those gross charges, not just what their actual financial responsibility is. So again, I think billing continues to be more complex than it needs to be as an industry," he said.
Price transparency has come a long way in the industry, but certain populations may need more education on what they are seeing in that final bill and breaking down this overload of information is an important step in achieving a positive patient financial experience.
"I see it time and time again where throughout the continuum of care, the billing aspect of service is just not discussed. And even when a patient would proactively ask, 'How much does this cost?' that discussion goes 'Oh no, we'll just send you a bill,' " said Cox.
Bringing that conversation forward and setting the expectation that a patient may see a gross charge or mentioning to a patient that they haven't met a deductible will help remove that surprise element from the patient's bill, Cox said.
On top of this surplus of coding and pricing information, it's not unusual for patients to receive multiple bills from different providers for one episode of care.
"That can be confusing for patients. And again, it's not a problem that we have successfully fixed at this point," said Johnson.
Also, it's common for a patient's statement to not completely align with the explanation of benefits that the patient receives from their insurance company. Receiving multiple bills for one encounter as well as receiving mismatched facility and payer statements can greatly affect the patient's financial experience.
"While we are continuing to improve and provide better information to our patients, we have a more ground to cover in making this industry and process truly patient-friendly," Johnson said.
Potential solutions
So, what can organizations focus on to improve the patient financial experience?
Being able to articulate to patients how much they owe in a clear and concise manner is critical and has been brought to the forefront by the No Surprises Act. An opportunity to improve a disconnect in communication can start as early as patient scheduling, check in, or check out.
"Providing this information to patients at all of those different touch points, having that discussion with the patient, and just setting the right expectations can improve that patient financial experience," Cox said.
Another solution to improve on the billing and collection process is simply having those back-end staff be more friendly and understanding, said Cox.
"I've never received a phone call where I pick up the phone and I'm like, 'Hey, you caught me at a great time. I'm so happy you called me,'" said Cox.
"All times are equally inconvenient for patients, and finding a better medium to contact patients or even giving them the ability to schedule a call through text and say, 'Would you like to schedule a call with us to discuss your bill?' Those are some areas where I think we could make it a little bit more friendly and ultimately improve the financial results of this process," he said.
Johnson agreed and added that although burdensome to some hospitals, the move toward price transparency is only going to help improve that patient financial experience, especially when patients are educated on the information they are being presented.
"I know it's been a difficult journey for a lot of us, and the rules that require us to do some of this don't always line up with reality of either what we can do or what needs to be done. But I still believe that it should be considered a positive thing because, ultimately, it's going to give patients more information about what they will ultimately owe out of pocket and options for resolving the out-of-pocket expense," Johnson said.
The revenue cycle space is seeing a boom in automation and technology, giving patients better access to patient portals, digital front doors, and payment options.
While patients may be getting an information overload through their bills and statements, once this information is paired down and streamlined, the advancement of technology can make the patient financial experience easier and more transparent.
Johnson echoed this point by saying that "healthcare has been providing more and more information to the patients through online portals. We are moving down multiple payment paths, trying to make that a component of the patient experience as easy as it can be."
"The ultimate goal is to give the patient the information they want, when they want it, where they want it, and how they want it, including the ability to make payments and to interact with us on their financial issues in any manner that they see fit," he said.
The growth of more payment plan options have also been a key solution in bettering the patient financial experience. Most organizations are dealing with patients who have higher out-of-pocket expenses, and it's becoming more likely that patients are routinely unprepared to pay the out-of-pocket expenses.
"When you carry $3,000, $5,000, or $10,000 out-of-pocket maxes, most patients aren't walking around with either that kind of money or the ability to write a check at one point in time. And I think the industry is responding to that, and providers are responding to that to try to make the payment mechanism for those out-of-pocket expenses easier for patients to navigate," Johnson said.
Finding solutions to these common patient billing pitfalls is imperative for organizations.
"The mindset should be that the patient financial experience needs to follow the same path as the clinical experience," Johnson said. "They both need to be phenomenal in order for our patients to be satisfied with the organization providing the service."
"It's important that we're setting the right expectations so that way when patients get a bill, they're not surprised. We want patients to not only pay their bill, but we want them to come back. That patient leakage is incredibly important to track and monitor, and organizations need to have a plan on how to minimize it moving forward," Cox said.
