The New Rules of Revenue Cycle: Adapting in an Era of Change
Vice President, Payer Strategies and Contracting
Timothy J. Reiner
Vice President of Revenue Management
Adventist Health System
Chief Operating Officer
Patient Financial Services Orlando Health
Senior Technology Editor
HEALTHLEADERS: How will healthcare reform affect revenue-cycle management? What role will technology play?
Deborah Lelinski: Healthcare reform is driving the movement to high-deductible health plans. The rise in self-pay alone is going to demand more interaction with patients about their ability to pay before they receive treatment. Technology can make this conversation between the healthcare provider and the patient easier, more streamlined, and lead to prospective payment arrangements that are satisfactory to both the provider and the patient. Technology will also bring greater efficiency to the revenue process. We can't continue to work in a manual fashion. We don't have enough FTEs to continue to do revenue work as we do it today.
Timothy J. Reiner: As much as I want to say the solution is to hire more people, I'm not sure that's where we need to go. The answer will be to invest in better technology, faster technology, more accurate technology. It's going to be connectivity not just with the payers, but, in regard to the ACO model, with everyone. Where does that patient fit into the whole continuum? What is the benefit structure like? And how does each of those visits they've had throughout the continuum with different-level providers impact what they owe you when they are there in front of you—or hopefully, before they present or when they schedule. Can you accurately calculate it? Can you efficiently collect it?
Thomas Yoesle: It's challenging from a patient education perspective: telling patients why they owe more money than in the past, interpreting new rules, helping patients into the right programs, and helping them understand those programs.
Richard O'Donnell: Insurance exchanges could take that role of interpreting benefit design. They're going to define what's gold, what's silver, what's bronze in terms of out-of-pocket liability, and that's going to have a huge impact as to how people choose a plan and what level of personal liability they want to assume. That has implications for the providers in terms of collectability.
Reiner: But we're still going to have to engage the patient in different ways once those exchanges become more prevalent in the various states in 2014. It may be online portals or other strategies. There is a lot we don't know, but clearly one of the tenets of meaningful use is to engage the patient more online in their care—including their financial responsibility.
Yoesle: As much as I want to push this education and information to the Web, I think we'll start hosting workshops and using kiosks to answer questions about benefits and plans and then push those FAQs to the Web. Right now, that education is happening over the phone in the centralized scheduling area.
Lelinski: Technology can play a huge role in helping consumers understand their plans, their benefits, and the amount they must pay out of pocket. Once I, as a consumer, have that information, I'm going to go where I can get the best deal—the best quality for the best price. Right now, it's very difficult to realistically predict the cost of service when the complexity leads us to answer with "It depends."
Reiner: Estimating benefits is something that we've struggled with from the Stone Age. As a provider, you've got to decide whether to invest in additional technology beyond just pushing a button and sending a transaction to the payer or screen scraping [capturing computer screenshots and putting them into a database]. We should be so much better than this.
O'Donnell: We need what I would call real-time patient liability estimators—complete interconnectedness between health plans and the clearinghouses and the providers. Let's allow the patient in this brave new world of consumerism to go into their own portal through the provider, get to their data, and pull back what their unmet liability is. And it's still not 100% certain, so we put disclaimers all over it. But it's so much better than having someone asking 20 questions to identify your possible out-of-pocket liability that may still be inaccurate.
Yoesle: It's a failure of both providers and payers that we haven't opened this up as a Web service.
HL: How will health plans that shift more of the cost to policyholders affect patient utilization?
O'Donnell: Honestly, I think we have to categorize the impact of healthcare reform on patient utilization as a great unknown. Any actuary that walks in and tries to convince us that they can anticipate the impact is wrong. With consumer-directed health plans, the actuaries advised the insurance industry on premiums and product pricing based on anticipated utilization and out-of-pocket costs. And I don't believe a lot of those predictions came true. In fact, consumer-directed health plans faded into history.
Lelinski: There is a hypothesis that the financial burden placed on consumers through high-deductible plans will hinder quality outcomes if patients put off a test or don't fill a prescription, for example, because they're paying for it out of pocket.
Yoesle: Presumably that risk is going to be on the payers and the exchanges. They're going to have to intervene more to mitigate the risk. Will a $100 private insurance copay for an urgent care visit discourage someone from going? It might. It may drive up the cost of overall care. But that's going to be the private payer's problem because they took on the risk.
O'Donnell: The question is, are you going to shop for total price on a higher-level service with the same zeal that you might with a thyroid scan? As the complexity of the service expands, I think the consumerism piece fades back.
HL: How will collaborative and accountable care models affect revenue and collections?
O'Donnell: I have this hypothesis, though I may be proven terribly wrong, that you have a much better chance of collecting out-of-pocket liability when there is a longitudinal relationship between the patient and the provider. Primary care physicians have better luck with collections than a hospital or a subspecialist. In an accountable care organization, though, since we are attributing patients to providers and they are being encouraged to stay within a coordinated care environment, you are creating more of that longitudinal relationship between the patient and a set of providers. We need to build off of that and take advantage of that relationship.
Yoesle: In the ACO and the medical home models, one of the intents is to have more communication with your primary care provider. And the medical home could be where you collect for primary care, specialist, and hospital payments. How do you work on those relationships? Because now I have to build a relationship not just with the patient but with the office manager of that medical home that we just partnered with and say, "Hey, by the way, can you collect on our bills, too? Because the patient likes you more and will respond better to you than they do with me in the ED when I'm constrained by EMTALA laws." So maybe that's a collection methodology, and we give them access to our collection and patient accounting system.
Lelinski: I'm also excited about the concept of patient relationship management. How do you drive the highest possible chance of obtaining payment? It has to do with the relationship. Our statistics and our customers' statistics show that you can establish a relationship if you know the patient's total debt picture and how that impacts his or her ability to pay. You can make accommodations to renegotiate the payment plan, for example. Another important piece is obtaining that promise to pay.
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