Since starting cost estimations for a wide range of inpatient and outpatient services a decade ago, Oklahoma-based INTEGRIS Health has achieved a 22-fold increase in point-of-service collections.
Providing pre-service cost estimates to patients has markedly increased point-of-service collections at INTEGRIS Health, from $900,000 in 2007 to $20.55 million last year.
"It most definitely contributes. Providing financial information prior to the scheduled appointment gives the patient an opportunity to pay during the pre-registration call or at the time of service," says Veronica Hughes, administrative director for patient access services.
The Oklahoma City-based health system started providing out-of-pocket cost estimates for patients manually in 2006.
The majority of cost estimates are partially automated because fully automated estimates available through the health system’s website have not been widely adopted, says Brent Grimes, administrative director of revenue cycle. Most patients get cost estimates either over the phone or in person at inpatient pre-registration or when they appear for outpatient services such as laboratory tests.
Providing cost estimates has become a standardized procedure for patients at INTEGRIS' seven acute-care hospitals, Hughes says, noting estimates not only boost point-of-service collections but also engage patients as financial partners.
"We have an access center with centralized pre-service financial counseling and pre-registration. They contact upcoming scheduled patients to notify them of potential financial liability."
Technology and specificity
The key technological component of both fully and partially automated cost estimates is Franklin, TN-based Experian Health's Passport platform, she says.
Passport has most of the data required to make accurate cost estimates such as payer contract information, patient benefits, medical procedure pricing, CPT codes, and physician information.
"It looks at all of those elements for an estimate," Hughes says.
Specificity is crucial to providing accurate cost estimates, particularly for services with wide variability such as surgical procedures, Grimes says. Several specific components are required to provide an accurate surgery estimate:
- Contracted rates with the payer
- Identity of the physician, because different clinicians use different surgical supplies
- Supply chain information to ensure pricing accuracy of surgical supplies
- Historical claims data to help predict procedure costs
"Our estimation accuracy rate for surgical procedures today equals our other procedures," Grimes says. "We don't have any more variation in surgery than we have in radiology, for example."
Emergency care is the only hospital department where INTEGRIS patients do not get cost estimates.
"Even when we are asked, there is no financial communication or information before the patient is triaged, checked by a provider, and stabilized," Hughes says.
In emergency medicine, there are too many variables to provide cost estimates before services are provided, Grimes says.
"When people call in, we have to explain there is a triage process and we can't give out quotes before the triage process."
Monitoring accuracy
The health system's customer service group leads the effort to monitor the accuracy of patient cost estimates. A panel meets every week to go over logs that are kept on patient questions and concerns, including cost estimate complaints, Grimes says.
Inaccurate cost estimates are investigated.
"An analysis sees whether we had the proper information and whether it had been loaded properly," he says. "We see whether the patient understood that they had an estimate instead of what they would actually owe."
A refund team is part of the customer service group.
The issuing of refunds is an indicator of "root-cause" problems that need to be corrected, Grimes says. "If we are giving money back to the patients, we are failing at the process."
An example of a root-cause problem that can necessitate a refund is a health plan contract change that the estimate did not include.
"This could change the patient responsibility and create a situation that our estimate and payment upfront was more than the new contract allowed," Grimes says.
The response to this kind of problem includes researching the credit and communicating the corrective action throughout the cost-estimation team, he says.
An important step to avoid disappointing patients is consistent scripting when estimates are given, Grimes says.
"We try to be very clear with the patients that there are variables—some we can control and some we can't control—and we push the point that we have given an estimate."
Whenever possible, patients are asked to sign a copy of their cost estimates.
Lessons learned
INTEGRIS, which posted $1.55 billion in total operating revenue for the fiscal year ending June 30, 2017, devotes considerable time and resources to its cost-estimation capability.
"It takes an enormous amount of resources and people to do this well and keep up with it. There is continual maintenance and quality assurance," Grimes says.
INTEGRIS staff inside and outside the revenue cycle division are involved in cost estimation:
- IT maintains files and transfers data
- The charge master team manages pricing
- Contracting updates payer contracts
- The business office oversees customer service
- The refund team plays a customer service role
- The billing team handles the challenge of serving insured patients vs. uninsured patients such as helping patients obtain Medicaid coverage
- The charity team ensures compliance with 501(r) federal tax requirements
- The legal team reviews policies and documents
- Clinical teams provide diagnosis information
"There are behind-the-scenes pieces that are very easy to miss in the flow of business," Grimes says.
To maintain a robust cost estimation capability, Grimes says Passport must be continually updated with changes to payer contracts and medical-service price adjustments.
"Another key is consistency," Hughes says. "You need to standardize processes such as scripting for collection techniques—what a patient experiences at one facility should be the same as what a patient experiences at another facility. Also, you want consistency in important policies and procedures."
Consistently following up with patients who have received cost estimates helps drive point-of-service collections, she says.
"For the check-in staff, if there is an arrangement to pay, they can see that quickly and collect."
Christopher Cheney is the CMO editor at HealthLeaders.