Efforts to improve patient billing progressing slowly

Making patient bills more understandable for patients has become a wider strategy for MetroHealth, a Cleveland-based delivery system. It’s involved more than redesigning paper bills.

In fact, the organization has examined and changed how it communicates with patients before an encounter, and it’s developed an eligibility call center to help patients determine insurance they may be eligible for and get them signed up.

MetroHealth and other organizations see a rising need for making the billing process understandable, particularly as they see a rising need to engage patients in their entire care delivery process.

Ten years ago, the Healthcare Financial Management Association launched the Patient Friendly Billing Initiative, an effort to better standardize and make patient bills more understandable for healthcare consumers, assisting them in determining what was billed, how much insurance covered and the amount for which they were responsible.

The Patient Friendly Billing philosophy aims to ensure the needs of consumers are paramount when designing administrative processes and communications. Information gathering should be coordinated with other providers and insurers and done efficiently, privately and with little duplication; communications of financial information should not occur during a medical encounter, and the average consumer should easily understand the language in the bill, and feedback from consumers should inform continuous improvements in billing processes.

A decade later, it isn’t clear just how successful the program has been. The initiative got off to a good start with some muscle behind it, but since it’s start, it has taken time to really take hold, says Brian Eastwood, a consumer engagement analyst at Chilmark Research. Even today, it is common for patients to struggle with an explanation of benefits and not understand what they owe.

In part, that’s because when Patient Friendly Billing started, patient engagement wasn’t a national initiative, he notes. During the past decade, there has been more discussion of patient engagement in the billing process, but it generally was limited to ancillary sessions at conferences, Eastwood says. In the past two years, driven by increased patient financial responsibility, that has changed.

In 2011, the Office of the National Coordinator for Health Information Technology launched the Investing in Innovations Initiative, with $300,000 in prize money available. HFMA, Eastwood believes, should piggyback on that approach and launch a program to rethink the way patient bills should look and highlight examples of winners to show its members new ideas.

Sandra Wolfskill, director of healthcare finance policy at HFMA, has a decidedly different take. In short, Patient Friendly Billing is an overarching program for what makes a high-performance revenue cycle process in a provider organization and in large part it has worked, she contends.

But there have been bumps along the way, particularly early on when real-time electronic insurance eligibility verification and benefit transactions were in their infancy; but today, those electronic exchanges are used by nearly all providers. Over time, the dreaded telephone calls to insurers to get payment and benefit information have largely been eliminated.

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During the past two years, patient financial price transparency has become a high priority as consumers have become vocal at wanting to know what a procedure is going to cost, and what their financial portion will be, before the procedure is done, Wolfskill says.

That has fostered newer information systems from revenue cycle software vendors in the past few years, enabling providers to go through the same payment calculations as insurers to understand the status of a patient’s coverage, based on the provider contract with an insurer and the patient’s responsibility, she explains. “I can load contracts and electronically see what I need from the payer and patient.”

Now, smartphones appear to be driving the payment process, Wolfskill predicts. Patients want pricing information and will want it sent to their phone, and not have to call and wait on hold. “There’s some of that out there today, but it’s very limited.”

Vendors, however, are taking notice. App vendor Zocdoc, for instance, enables patients to find providers in their network and get estimates of charges via a smartphone. This is going to increase price transparency, which providers must start preparing for, Wolfskill cautions. “Posting charges on a web site doesn’t help the patient much.”

MetroHealth, a Cleveland-based delivery system anchored by 702-bed MetroHealth Medical Center, a skilled nursing facility and 25 health centers, about six years ago realized the need to figure out how to set patient expectations for payments, says Donna Graham, senior director of revenue cycle.

The organization implemented processes to reach out to patients before an encounter when patients did not have any insurance coverage registered with MetroHealth. An eligibility call center was established, and certified healthcare access associates work with patients to determine what types of insurance they may be eligible for and get them signed up.

It wasn’t necessarily a case of patients not thinking about or wanting insurance, Graham explains. For example, some believed that because they were working they were not eligible for Medicaid, when in fact they were. In 2014, an effort started that continues today to move out in the community, seek out the underinsured and enroll them in Medicaid.

MetroHealth repurposed a recreational vehicle and went through neighborhoods engaging residents, getting them insured, setting up access to primary care, enrolling them in the Epic MyChart electronic health record, and distributing clothing, toothbrushes and other personal necessities. Another program in 2014 eliminated co-pays for certain populations based on their financial status Graham notes. “It was a de-motivator for patients to see their doctor so we removed the co-pay from the financial/administrative business.”

Under the Patient Friendly Billing philosophy, MetroHealth went further in patient engagement. The delivery system established a precertification program to streamline patient pre-authorization processes before a procedure, coupled with explanations of the upcoming procedure and what the patient payment responsibility would be. A medical cost estimate for self-pay patients was put on the MetroHealth web site along with a link to talk to a billing representative about payment issues.

Further, MetroHealth has combined professional and hospital bills under one statement and is working on creating more user-friendly terminology, such as calling a urinalysis a urine test. Anesthesia has not yet been put in user-friendly terms; it has proven difficult to do so, Graham says.

The organization has twice received HFMA recognition for patient financial communication, and recently was named one of six hospitals to participate in the MadPow Initiative of the Department of Health and Human Services and AARP to design more understandable bills.

MetroHealth also is pilot testing with a major insurer to combine an explanation of benefits with a patient statement. In another engagement initiative, birthday cards go out to patients reaching age 65 with a reminder to sign up for Medicare and take advantage of its wellness programs.

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