When healthcare prices are transparent, the market will help determine whether costs go up or down, he says.
Editor's note: This is part two of a two-part interview with Eric D. Hargan, former deputy secretary of the U.S. Department of Health and Human Services. Read part one here.
When it comes to healthcare prices in the United States, Eric D. Hargan, former deputy secretary of the U.S. Department of Health and Human Services (HHS) and its former chief regulatory officer, doesn't necessarily want them lower or higher as a result of price transparency efforts.
"I would rather see prices that reflect reality," he told HealthLeaders.
And one way to get there, he believes, is for healthcare prices to be transparent, allowing the market to help determine whether costs go up or down.
"I think right now the system of third-party payment makes that opaque, makes it very difficult to understand what the prices are," he says. "And that makes it hard for us to have any of the discipline that markets give us in other of our economic sectors."
Right now, he argues, patients typically don’t know what they're going to pay for healthcare services until weeks or months after they've received them, resulting in patients who are "surprised" and "don't have any control" over what they're buying. It's a situation that's "nearly unique to the healthcare sector."
Unlike the No Surprises Act, which is calls more "determinative" and "prescriptive," price transparency aims only to "get the knowledge out there."
Once patients have that knowledge, Hargan argues, they can make their own decisions about where to receive care and—ultimately—where to spend their money.
Of course, making purchasing decisions always comes down to more than cost: Consumers want to know whether a product is worth its high price tag.
That's a hard enough question when it comes to low-stakes purchases like mattresses or sneakers, but what about healthcare? Is getting an MRI at a prestigious academic medical center worth the higher price tag than getting one at the community hospital in the town next door? And how could consumers know?
"You're asking the person that convened the Quality Summit at HHS and helped bring into being the National [Health] Quality Roadmap," he notes. "I think when prices are exposed and more information gets out there, they'll actually be a market for quality."
He also notes that quality information about hospitals and health services already exists in the market, and it's only a matter of time before "an intelligent consumer of healthcare services" will "able to use quality information—whether scores or other types of quality information—to determine what they want to buy."
However, there are still major barriers in place that prevent the kind of easy comparison shopping you might find on Amazon where prices are listed alongside consumer reviews for multiple competing products.
Although some health price and quality information might currently be available, it's not easy to find and certainly isn't aggregated in any meaningful way. Today, it would take a lot of expert legwork to comparison shop based on cost and quality for healthcare services.
But that, too, has the potential to be solved by the market, Hargan suggests.
"I think there'll be a market for intermediaries who will help consumers, patients, and so on understand the world of quality and the world of price and package it in a way that makes sense for the consumer," he says. "I have great faith in the ability of the programmers to create apps and all kinds of intermediaries that will allow patients to be able to do this."
He compares the current situation to when the Medicare Part D program was first implemented, noting that Saturday Night Live even sent up the program because people thought it was so complicated that seniors would never be able to understand it.
"Nobody thinks about everyone being confused about Part D, but they were years and years ago," Hargan says.
Now, though, it's a popular program.
"And I think the same thing will be true of the price and quality information over time," he says. "I'm optimistic that when prices are known and … quality is known, there'll be a market for quality."
Read part one of HealthLeaders' interview with Hargan here.
Advanced EOB requirement guidance, interim final rule disappointment, and the effect of surprise bills on consumers take center stage as the No Surprises Act effective date approaches.
With No Surprises Act requirements just around the corner and portions of the rule still in the interim stages, it makes sense that there's been a flurry of news related to surprise billing, the arbitration process, and more.
Here's a look at what some industry players have to say about surprise billing:
CAQH CORE releases advanced EOB requirements guidance:CAQH CORE released guidance for how healthcare providers and plans can meet the advanced explanation of benefits (EOB) requirement included in the No Surprises Act.
It's also hosting a webinar about those guidelines on November 17.
The guidelines include an advanced EOB workflow and implementation approaches for "good faith estimates," as well as recommendations for messaging standards, connectivity methods, uniform data content.
Among other things, the No Surprises Act requires:
Health plans to provide members an advanced EOB for scheduled services at least three days in advance
Providers and facilities to verify, three days in advance of a service and no later than one day after scheduling a service, the type of coverage the patient is enrolled in
Providers to give the health plan a "good faith estimate" of charges
The American College of Emergency Physicians (ACEP) speaks out: The American College of Emergency Physicians (ACEP) is calling on the Biden administration to change the interim final rule that details how to implement the No Surprises Act, which it called a "giveaway to insurance companies" that will "will undermine the entire effort to solve surprise billing."
It says that the interim final rule "would have arbiters give unequal weight to the qualified payment amount (the insurer's artificially low median in-network rate for reimbursement), rather than a balanced mix of other factors in the process."
As a result, the ACEP says this "would drive reimbursement rates lower and encouraging insurance companies to narrow their networks even further, which would make it harder for patients to get emergency care."
The ACEP also cites a November 5, letterthat Reps. Tom Suozzi (D-NY), Brad Wenstrup, DPM (R-OH), Raul Ruiz, MD (D-CA), and Larry Bucshon, MD (R-IN) sent a HHS Xavier Becerra, Labor Secretary Martin Walsh, and Treasury Secretary Janet Yellen urging them to "amend the IFR in order to align the law's implementation with the legislation Congress passed."
"Unfortunately, the parameters of the [independent dispute resolution] process in the IFR released on September 30 do not reflect the way the law was written, do not reflect a policy that could have passed Congress, and do not create a balanced process to settle payment disputes," the letter says.
The letter has an additional 125 Congressional signatories.
Surprise billing remains a problem for consumers: While stakeholders argue over and grapple with the details of how the No Surprises Act should be implemented, consumers are still feeling the pain of surprise bills.
eHealth's biannual "Health Insurance Trends" report, which included a survey of more than 6,400 consumers and 15 health insurers.
It found that 50% of the general population had a surprise medical bill in the past 12 months alone, and of these, 38% said the bill was a surprise because they didn't realize there would be an out-of-pocket cost for their care.
An additional 38% said the out-of-pocket charge was higher than they anticipated and 24% said the medical claim was incorrectly processed.
Women were more likely than men (54% vs 45%, respectively) and Hispanic people (60%) were more likely than Black (56%), Asian (52%), and white (46%) to get a surprise bill in the past year.
Only 31% of Medicare beneficiary survey said they've had a surprise bill in the past year.
TransUnion Healthcare has processed an increasing number of financial assistance transactions every year since it began tracking that data.
A new analysis from TransUnion Healthcare found that the number of financial assistance transactions that it processed increased 55% between September 2020 and September 2021.
That's an indication that hospitals are working more proactively to understand patients' financial needs, the company says.
The analysis looked at data from more than 1,000 hospitals and physician practices. TransUnion Healthcare conducted these transactions to validate a patient's identity, determine charity options, and assess their ability and propensity to pay.
The increased number of financial assistance transactions was also likely exacerbated by the economic downturn caused by the pandemic.
"Our analysis found this increase reflects both higher numbers of patients struggling with medical bills and hospitals seeing more value in using our data to efficiently and accurately determine which patients truly qualify for financial assistance," Jonathan Wiik, principal of healthcare strategy at TransUnion Healthcare, tells HealthLeaders via email.
TransUnion Healthcare began collecting this data in September 2018 and has tracked an upward year-over-year trend, amounting to a 270% increase since that time.
Its financial assistance transactions increased 49% from September 2019-2020 and 60% from September 2018-2019.
A separate TransUnion Healthcare consumer survey of patients’ healthcare billing experiences found that 35% of those with outstanding medical bills said those bills deterred them from seeking healthcare in the past 12 months.
"This data reflect the increased financial pressure on healthcare systems as well as patients who are struggling with the burden of high healthcare costs," Wiik said in a statement. "We are recommending that hospitals engage patients confidently and increase transparency and communication in regard to billing, beginning with providing patients a clear understanding of the cost of care at intake, and then streamlining financial clearance and charity screening throughout the revenue cycle."
"It's the people that recognize the shape of things to come and help participate in it … who will have a chance to shape what goes forward," Hargan says.
Editor's note: This is part one of a two-part interview with Eric D. Hargan, former deputy secretary of the U.S. Department of Health and Human Services.
Rate hikes are coming for hospitals that aren't compliant with the CMS price transparency rules, but according to Eric D. Hargan, former deputy secretary of the U.S. Department of Health and Human Services (HHS), as well as its former chief regulatory officer, that shouldn't have come as a surprise to hospitals, given that it's been embraced by two consecutive—and very different—presidential administrations.
"You've got two administrations coming from two different parties and operating [with] pretty different overall policy directions in many, many different ways," he tells HealthLeaders. For hospital executives, that agreement should signal that "the political stars" are aligned on price transparency.
That means that any revenue cycle leaders who've been hoping that this issue would somehow fade away or that the new Biden administration would scrap it altogether, shouldn’t hold their breath, especially since Biden is continuing—and even bolstering—the Trump directive.
"Ask [Biden and Trump] on most things, one would say X and the other one would say not X. But when they both say, 'Yes, price transparency, let's put it in an executive order each of us signs,' you should take that as a pretty strong clue that the government is very much aligned on this issue," he says.
Hargan is currently the founder and CEO of a consulting firm, The Hargan Group, and recently joined Amino, a digital healthcare guidance platform, as a company advisor. In that role, Hargan and his firm will provide policy and strategy support to Amino as it develops software and solutions to help clients comply with price transparency and the No Surprises Act.
As one of the architects of the price transparency rule, Hargan has spoken to a lot of hospital leaders both during his HHS tenure and since and has heard their concerns. But he doesn’t think simply ignoring the rule and accepting the fines for noncompliance is the right course of action for those who don't think the rule is useful.
Here are three reasons why Hargan thinks compliance is the best course of action for hospitals.
1. The fines are going up
"If you just simply say, 'I'm not going to comply, forget about it. I'll take the fines,' the government may take that as a signal that, well, I'm not getting compliance, I'll just go ahead and increase the fines until I get compliance," he says. "That's not really a situation where you want to be."
Indeed, CMS said in its final Outpatient Prospective Payment System (OPPS) rule for 2022 that the fines are going up. It said it will set a minimum civil monetary penalty of $300 per day for hospitals with 30 or fewer beds. Hospitals with more than 30 beds will be charged $10 per bed per day, which will cap at $5,500 daily, and the maximum total penalty amount would be $2,007,500 per hospital.
2. You'll have more credibility to tell the government what's wrong with the rule
"I wouldn't say we put out a rule that we thought was a bad rule," he says. "We put out what we thought was the best rule that we could do."
However, he does acknowledge that the rule may not be perfect and says there's only one way for hospitals to prove that to the government: By earnestly trying to put the rule into practice and learning firsthand where it can be tweaked and improved.
"When the government approaches a new area and a new rule, I won't be surprised that it wasn't perfect," he says. "In implementation, when it's intelligently engaged in by industry, [hospitals can say] this doesn't work, or this section doesn't work. That part doesn't work. This is too costly. This takes too long. This absorbs all our staff."
He points, as an example, to the CLASS (Community Living Assistance Services and Supports) Act, a voluntary long-term care insurance program, which was ultimately scrapped in 2011 by the Obama administration.
"HHS tried very much to implement that," Hargan says. "And then they finally threw their hands up and said it just doesn't work."
For the government to learn that a rule doesn’t work, though, hospitals need to earnestly and wholeheartedly try to implement it, and not with a "ham-fisted attempted implementation that was always going to fail," he says.
Only then, Hargan believes, will hospitals have real authority with the government in illustrating exactly how and why the rule doesn’t work.
"You can't act until you know what the problem is. And the problem doesn't show up until there's an attempt to implement," he says. "That's where you get credibility in re-approaching this rule."
3. Participating hospitals may have a say in the next generation of price transparency rules
Participating in what Hargan calls the "first generation" of these rules, also allows hospitals to get a say in what a revamped rule might look like.
It "allows people to have a seat at the table and determine where these things are going to go in the future because I don't anticipate this is the last word on this issue," he says. "Being at the table is the best place to be early on. And I think it's early on. It's my best guess we're early on in that process and it's going to persist over [presidential] administrations, just like value-based care did."
In other words, the price transparency rule is just one part of a larger trend in healthcare that's not going away, and hospitals that participate early will be in the best position to shape what that rule and other rules look like in the future.
"It's the people that recognize the shape of things to come and help participate in it … who will have a chance to shape what goes forward," Hargan says.
Stay tuned for part two of this series where Hargan discusses what he envisions as the future of price transparency and healthcare costs, as well as how the No Surprises Act fits in.
A perfect storm of factors leads to the median operating margin dropping 18.2% from August to September, not including federal CARES Act funding.
Hospitals and health systems are experiencing an "alarming and sustained" increase in expenses and plummeting margin declines, according to a new report from Kaufman Hall.
The October National Hospital Flash Report describes a perfect storm of factors leading to the median operating margin dropping 18.2% from August to September, not including federal CARES Act funding.
These factors include high numbers of high-acuity patients, overall volume decreases, and rising expenses.
For example, patient days decreased 1.4% from August to September, likely due in part to a decline in COVID-19 patients. However, the average patient length of stay rose, discharges decreased, and patient days remained high relative to pre-pandemic levels.
From August to September, hospitals also saw:
Adjusted discharges drop 5.1%
Gross operating revenues decrease 1.4%
Total expense per adjusted discharge increase 7.6%
Expenses and revenues in September climbed above both 2020 and 2019 levels, and at the same time there was also a 3.3% drop in outpatient revenue from August.
According to the analysis, this suggests possible consumer worries about accessing care during the recent Delta variant-related surge.
"Multiple factors are contributing to alarming and sustained increases in hospital expenses," the report's author, Erik Swanson, senior vice president of data and analytics, said in a statement. "Growth in labor expenses are outpacing increases in hours worked, suggesting hospitals are paying more due to nationwide labor shortages. Rising supply and drug expenses also point to worldwide supply chain issues."
Here are some additional report findings for hospitals:
Patient days increased 11.4% year-over-year and 9.3% year-to-date, but dropped 1.4% from August to September, reflecting a decrease in COVID-19 related hospitalizations.
Average length of stay increased across the board, up 4.8% year-over-year versus 2020, and up 8.2% year-over-year versus 2019.
Gross operating revenues (not including CARES) jumped 16.6% year-to-date and 12.3% year-over-year, versus 2020 and 10.4% year-to-date and 18.2% year-over-year versus 2019.
Total expense per adjusted discharge was up 2.6% year-to-date and 12.9% year-over-year.
Kaufman Hall also published a Physician Flash Report for October, which showed that physician groups saw significant revenue and productivity gains in the second and third quarters.
Physician expenses, however, climbed above pre-pandemic levels for a third straight quarter, due in part to increases in non-labor expenses such as drugs and medical supplies.
'If you can get it right up front, you're ensuring accuracy, preventing rework, and preventing denials,' says Alicia Auman, director of patient access at KSB Hospital.
Patient access plays a tremendously important role within the revenue cycle, which is why Alicia Auman, director of patient access at KSB Hospital in Dixon, Illinois, has worked so hard to transform her department from top to bottom, starting with how it's viewed by everyone else.
"We really had to focus on changing the mindset of the organization to understand that access was not just registration," she says. "I worked with the CFO to change the mindset."
Instead of viewing patient access as simply a data-entry role, these staffers are now viewed as "front-end billing experts, trained on how to properly identify rules, plans, and policies, and understanding that access handles 70% of what goes out on a claim."
"If you can get it right up front, you're ensuring accuracy, preventing rework, and preventing denials," Auman says.
Auman talked with HealthLeaders about the steps KSB Hospital's patient access department took to revamp the way it was organized, the way it worked, and its results. The conversation has been lightly edited for length and clarity.
1. Bring All Registration Staff Together
"One of the first things that I did was make sure that we had all the registration staff working under one umbrella. Historically everyone was separate. We have the hospital and some outlying clinics, and I had about 21 people on my team, which consisted of the hospital and just one clinic that was attached.
I worked with the outlying clinics and the clinic management teams to explain why it was important to have registration report to access. Those people were never connected to access and didn't really understand the impact they're having on the revenue cycle and negative impacts on the revenue cycle.
They knew that they're scheduling appointments and creating an encounter so the doctor can do their work and document. But having them join the [access] team was tremendous, for not only the organizational success of the revenue cycle but for those people to understand the work that they're doing and empowering them to know that they have the skills to do their job, do it well, and have a consistent process.
We were to get all the access team members under one umbrella and moved our department from about 20 people to about 70 people."
2. Implement Pre-Registration
"We implemented pre-registration to capture more accurate information and to expedite the check-in process. We had long lines at registration and [patients] feeling like they don't have any privacy. Now, we have patients share that they feel more privacy when they're doing the pre-registration process over the phone.
They like knowing that they've already given their information so they can just get in the line, give their name and date of birth, and get on their way to their appointment. Our check-in times for pre-registered patients moved from about three to five minutes per registration to about 45 seconds."
3. Use Front-End Technology
KSB Hospital implemented front-end technology from the company AccuReg, such as automated claim verification, front-end claim scrubbers that catch errors immediately, and tools to collect copays and payments at the point-of-service.
"You can't manage what you can't measure, and we had no way to measure any issues that we had. The billing department would just send me handwritten printouts … saying, 'this is incorrect,' with never any explanation as to what needed to be fixed or why.
We were getting things that were six months old or more, and billing wants us to go to the registrar and say, 'Why did you do this,' and 'you need to fix that.' And now it's way too old; nobody's going to remember why they did anything wrong.
[Also] when people were verifying [patient] information there was a manual process to push eligibility out to get information for that. We had complaints from providers on the long registration time and complaints in the billing office on not having correct information. The access team could never win. We were either getting yelled at up front or getting yelled at later on.
Now, [with AccuReg's quality assurance product] we have real-time edits that prompt the registrar to talk to the patient at the point of service. We have eligibility verification, which automatically checks eligibility.
When we started with [the tool], our baseline was 80% final accuracy. Now our initial accuracy rate is 95%. That that shows us that the staff are not only correcting but they're learning from things that they're correcting. Now our final accuracy rate is 99% consistently.
Our point-of-service collections are usually between $11,000 and $30,000 per week, depending on payer mix and our volumes.
Access related denials were around 21%, now they're around 7% of total denials.
And since implementation in 2019, [the technology] helped us to prevent $800,000 per month on average in denied charges, with more than $20 million in total savings … that would have been denied."
4. Cultivate Leaders and Educators
"We implemented a QA analyst and educator for the team to help streamline processes, make sure that we're being consistent with education, and to also maintain software needs.
AccuReg … has a lot of information and obviously you have to keep up with payer changes and edits. So, having a person dedicated to being an educator that would go out and do all this education for the team, in addition to looking at all the reporting that we have now, and understanding what the team's needs were for education is huge. Access is everywhere … in most organizations, your team is always spread out. So having one person, and having that one message of how to do something, is tremendous.
We also implemented leads for departments, like central scheduling, insurance verification, pre-registration, check in, and office scheduling. Having leads is awesome because now people have somebody to go to for their basic day-to-day workflow questions, and it also empowers those people to be the owner of that area of the department."
5. Develop a Career Ladder
"We developed a tiered pay scale. People who check in patients are paid in tier one. Once you have training and you've been in the department for a while, you can move into pre-registration, and you would get a little bit of a bump in your pay. You're growing a little bit; we trust you with more and more responsibility. Tier three would be the authorization team and financial counseling.
Since we implemented all of this, the staff satisfaction and our retention has gone up. Turnover was reduced by 42% to 25% in two years.
These people need to know how to do this job. It's not just checking the in patients; it's not just creating an encounter. There's important information that you need to get up front. And I think that we have changed that mindset in doing a career ladder.
It was awesome because I wanted to show people that you can come in to access. Don’t think of it as an entry-level position; think of it as an opportunity to build your skill set … you can go on to do something different in the revenue cycle … it really just opens their eyes [that] there's a whole career path within healthcare that's not clinical."
When consumers receive "payment due" notifications through their preferred digital channels about half will pay through that channel in less than an hour, and many will pay in less than five minutes, a new survey shows.
Texting people their bills or sending payment notifications through their preferred digital channels often results in bills being paid in minutes, according to research from AccessOne.
It found that when consumers receive "payment due" notifications through their preferred digital channels about half will pay through that channel in less than an hour, and many will pay in less than five minutes.
In fact, 32% will pay their bill in less than five minutes when they receive it via secure text; 30% will do so when they get the notice via a mobile app; 25% will pay within five minutes when they get it via email; and 25% will do so when they get it through the patient portal.
Healthcare systems have found success with texting in several ways.
For instance, Hartford HealthCare, a Connecticut health system, sent out 1.5 million texts to encourage COVID-19 vaccinations, resulting in 600,000 people engaging with the texts and pursuing the vaccine.
"I don't think you could do any other campaign where people could reach 600,000 respondents in one shot," Barry Stein, MD, MBA, FSIR, FACR, RPVI, vice president, chief clinical innovation officer, and chief medical informatics officer at Hartford HealthCare, told HealthLeaders.
The AccessOne survey also found that when it comes to paying for healthcare costs, consumers want three things: affordable monthly payment options (60%), clear communication (58%), and transparency around out-of-pocket costs (55%).
Additionally, it shows that:
41% of patients are confused about the portion of the bill that their insurance will cover.
39% are only somewhat or not at all satisfied with the quality of communications around how to pay for healthcare costs.
40% are only somewhat satisfied or not at all satisfied with affordable options for payment.
One third say communication regarding available payment plans for their bill could be improved.
57% of consumers are concerned about their ability to pay a medical bill of $1,000 or less.
62% want to discuss payment plan or financing options prior to a procedure.
58% have delayed medical care to avoid a healthcare bill, and one-third have done so in the past year.
71% would shop around for care, and 36% already have.
More than 80% of leading health systems that are using RPA/AI say their primary reason for investing in the technology was improving financial performance, but once the technology was in use, they said efficiency was the top benefit.
The reasons that leading health systems initially invest in robotic process automation (RPA) and artificial intelligence (AI) for revenue cycle management are slightly different than the benefits they report after actually using the technology.
That's one of the key takeaways from "The Promise of Robotic Process Automation and Artificial Intelligence in Revenue Cycle Management," a study by Waystar and The Health Management Academy that surveyed 50 health systems executives
More than 80% of leading health systems that are using RPA/AI say their primary reason for investing in the technology was improving financial performance.
But once the technology was in use, the primary benefits were different. In fact, increased revenue capture was actually the third (out of four) most important benefit to RPA/AI.
Instead, 91% of leading health systems currently using RPA/AI for revenue cycle management said that efficiency was the top benefit, over both cost reduction (82%) and increased revenue capture (74%).
According to the survey, RPA and AI usage remains inconsistent across the various parts of the revenue cycle and adoption rates are still very low.
It found that of the leading health systems that are currently using RPA/AI:
14% are using it for denial management
28% are using it for payment posting and reconciliation
40% are using it for claims management (statusing)
10% are using it for revenue capture/integrity
28% are using it for coding
22% are using it prior authorization
18% are using it for patient estimates
28% are using it for eligibility verification
6% are using it for patient registration
However, 64% of those surveyed plan to pursue these technologies within the next three years.
The report authors note that "the areas of RCM that are more aligned with AI capabilities, such as denials management, currently have lower rates of reported RPA/AI use…For example, when looking at diagnosing denials, only 38% of those who use RPA/AI technologies reported using predictive analytics to identify risk and the problem."
They survey also showed that the use of RPA/AI hasn't resulted in mass layoffs as many once feared.
Although 82% of leading health systems reduced their RCM workforce following the implementation of RPA/AI, 62% of executives reallocated staff to different roles while less than a quarter reported eliminating active positions. Additionally, less than 25% of LHS reduced their RCM workforce by more than 10%.
Establishing an electronic prior authorization process and requiring HHS to establish a process for "real-time decisions" for items and services that are routinely approved are two ways a new bill aims to streamline the way Medicare Advantage plans use prior authorization.
The burden of prior authorizations might be lessened soon thanks to new legislation with 227 cosponsors in the U.S. House of Representatives.
Establish an electronic prior authorization process
Require HHS to establish a process for "real-time decisions" for items and services that are routinely approved
Require Medicare Advantage plans to report to Centers for Medicare & Medicaid Services (CMS) on the extent of their use of prior authorization and the rate of approvals or denials
Encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians
Although health plans and providers agreed on principles to improve prior authorization in a 2018 consensus statement,three years later, the prior authorization process is as arduous as ever.
A Medical Group Management Association MGMA Stat poll earlier this year asked medical groups: "How did payer prior authorization requirements change since 2020?"
The vast majority (81%) said they increased, 17% said they stayed the same, and only 2% said they decreased.
In fact, many respondents said they had to hire additional full-time staff to handle prior authorization work.
94% of physicians report prior authorization-related care delays
79% report that prior authorization can at least sometimes lead to treatment abandonment
32% report that prior authorization criteria are rarely or never evidence-based
30% report that prior authorization has led to a serious adverse event for a patient in their care
21% report that prior authorization has led to a patient's hospitalization
18% report that prior authorization has led to a life-threatening event or required intervention to prevent permanent impairment or damage
9% report that prior authorization has led to a patient's disability/permanent bodily damage, congenital anomaly/birth defect or death
85% describe the burden associated with prior authorization as high or extremely high
"Paperwork should never get in the way of seniors accessing timely, critical care. Prior authorization is an important tool, but we need to bring it into the 21st century so that our seniors get the medical attention they need when they need it," DelBene said in a statement.
'We are the face of the patient financial experience,' says Terri Meier, director of system patient revenue cycle for UC San Diego Health, who shares three strategies for educating revenue cycle employees.
The revenue cycle is a critical part of every hospital and health system, but unlike coders, physicians, nurses, accountants, human resource managers, and other professionals, revenue cycle employees often don’t receive much formal education or training. Instead, many revenue cycle employees are hired at the entry level, learn on the job, and work their way up through the department.
That's why Terri Meier, director of system patient revenue cycle for UC San Diego Health, has made it her mission to provide education and training for her staff that goes beyond even the walls of her health system.
The need for well-educated and highly trained revenue cycle professionals will only become more important in the coming years, as technology automates rote tasks and expert employees are needed to handle more complicated accounts and situations.
"I think healthcare is ever evolving, and it is critical for us on the hospital and professional side of revenue cycle to keep up with the external environment and how quickly it's changing," Meier says. "That's where a foundation of educating your employees [comes in], not only in their day-to-day work and what their role and responsibilities are, but [in] keeping them abreast as to what is changing in the external environment."
A deep understanding of the revenue cycle is also needed as health systems and hospitals focus more heavily on patient experience.
"We are the face of the patient financial experience, customer service, and billing, as well as financial assistance," Meier says.
Meier told us all about the hiring, onboarding, education, and training program on the HealthLeaders Revenue Cycle Podcast. Read on for three strategies she talks about in that conversation and be sure to listen to the full interview, including how UC San Diego has partnered with a local college program for revenue cycle education and why a transparent management style is so important.
1. Provide a thorough onboarding process
Training on the end-to-end revenue cycle process via the EMR and completing customer service skill courses are just part of the extensive onboarding process that employees go through at UC San Diego Health.
Showing a high level of competency is required before they're ever put on the phone. For example, they need to test at 80% or greater for each of the customer service attributes they're trained on first. They also receive tip sheets and situation response guides to help them in customer service conversations.
"They know where they can go to find the answer to the patient's question," Meier says. "This way, they've got tools in their toolkit to be able to manage that conversation with the patient."
Another part of the onboarding process is shadowing and working side-by-side with each of Meier's team members, not only so the new employee can get to know their team but also to ensure that all employees are using the same consistent, standard workflows.
That's because when patients call customer service, it won't matter which customer service representative they reach.
"They're going to get the same experience, which is really important to us," Meier says.
2. Turn the career ladder upside down
Customer service usually is the easiest place for revenue cycle employees to start out, "and as soon as a billing job opens up, you lose that customer service rep to that billing job," Meier says.
That's not the case at UC San Diego, where customer service is the highest-paid revenue cycle position.
"UC San Diego actually was very invested in making that patient financial experience a differentiating factor. So much so that they have allowed me to hire knowledge workers," Meier says. "Customer service is hard because it's not only knowing the answer to the question, but it's also managing that human interaction with that patient. Most of the time … the reason why the patient is calling is because they have a problem, so it's not always an easy conversation to manage."
But with a higher salary comes "a higher expectation."
"My team is expected to know the end-to-end revenue cycle from the point of scheduling all through cash posting so we can figure out where the break is in the process when patients come [to us] with those problems," Meier says.
3. Make sure that education is ongoing
UC San Diego supports ongoing, day-to-day education in many ways, including daily huddles, where team members can bring up issues they are experiencing, find the root cause of the problem, and implement corrective action.
They also do annual competency testing and quality assurance reviews; have an education committee; and have applied for HFMA enterprise membership, "so all of our team members will be CRCR [Certified Revenue Cycle Representative] certified as part of our offering to them," Meier says.
Such ongoing education and quality assurance allows UC San Diego's revenue cycle employees to be laser-focused on their mission.
"I always told them that their first responsibility is to be the voice of the patient," Meier says. "The education really provides us with a good foundation to be able to deliver on that first-call resolution."
That focus is reflected in its metrics and cash collections. For instance, it has a 0.02% abandonment rate, and its service level is 99.87.
"It builds trust and loyalty with our patients," Meier says. "They call us because they know we can get the answer to their question and we're very proud of that."