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."
Challenges at the Michigan-based health system include revenue cycle optimization after the installation of a new medical record system and finding ways to match cost increases with the rate of general inflation.
Matthew Cox, CPA, MBA, has a lengthy list of goals as the new senior vice president and CFO of Spectrum Health, including optimization of a new electronic medical record, expansion of consumer-oriented programs such as online platforms, containing costs, and increasing risk-based contracting.
Prior to joining the 13-hospital Grand Rapids, Michigan-based health system, Cox served as senior vice president of finance operations at Phoenix-based Banner Health. Spectrum also owns a 783,000-member health plan, Priority Health.
HealthLeaders Media spoke recently with Cox, who is succeeding Ron Knaus after his retirement. Following is a lightly edited transcript of that conversation.
HLM: In 2018, what are Spectrum’s primary financial challenges?
Cox: Tactically, we just went live on Epic clinical and billing systems in our Grand Rapids hospitals, and our community hospitals and the remainder of the health system will go live in May. So, in my first 90 days, I will create a comprehensive assessment of the current state of revenue cycle. After that assessment, I will put together a 24-month work plan. We understand that we won't be able to maximize the functionality all at once, so we have asked our consultants to help our revenue cycle leadership develop a 24-month work plan to keep our improvements on track.
HLM: Why are you conducting the comprehensive assessment?
Cox: As a result of this system conversion, we have experienced a temporary increase in receivables, as expected. I expect we will see receivables return to historical levels by the end of our fiscal year in June.
We need to make sure we are optimizing the system, so it is easy for our providers and employees to use, and we get bills out to patients with the information they need in a way that's not confusing.
Patient-balance responsibility, co-pay and coinsurance, and pricing transparency in healthcare is not on par with other industries, and that is something I am going to be working on.
HLM: What is Spectrum's primary strategic challenge?
Cox: Strategically, the biggest challenge is shared with the entire industry—our insurance products and clinical services are becoming too expensive. The prices of services continue to outpace general inflation.
The entire industry is ripe for disruptive innovation, and we have to be better at controlling our costs and eliminating unnecessary utilization, then pass those improvements on to our customers.
There are a couple areas where we have been reducing costs. We have MedNow, where you can do virtual visits, and that helps drive down costs.
By implementing [the] Epic [medical record system], we are reducing duplication. When you have an electronic medical record that spans the entire health system, the providers can see the services that have already been done with patients, so they can avoid ordering unnecessary or duplicative tests.
We need to maintain our current financial strength, while lowering the cost to patients. Spectrum will continue to be strong into the future, but we have to operate in a way where our costs do not increase at a rate much greater than general inflation.
HLM: This year, what do you think are the biggest financial opportunities for Spectrum?
Cox: We're one of the few integrated health systems in the country that has a large and successful insurance company, which gives Spectrum operational and strategic advantages such as having our costs for patients lower than comparable health systems.
We also can continue to expand price transparency through Priority Health's cost estimator tool, which is an example of making healthcare easier and more affordable for patients.
We want to increase Spectrum's risk-based contracts with all major payers. We do a good job now on risk with Priority Health; but beyond that, we have very few risk contracts.
HLM: What are examples of consumerism growth at Spectrum Health?
Cox: We have MedNow, the MyHealth patient portal, and the Strive wellness platform, which are higher-end primary care that help patients manage their health. We've also got new integrated-care campuses that are close to patients' homes.
HLM: What is the key to managing growth?
Cox: You need to increase the level of benchmarking and financial accountability. This is an overarching goal: As we grow, I want to make sure there is strong financial rigor and our managers are held accountable to the plans that they put together. We want to be best in class when we grow and benchmark ourselves against the best in class performers.
I also want to increase the number of our partnerships, joint ventures and collaborations, both nationally with large companies that have deep experience that we might not have, and locally. We want to increase our collaboration with other organizations in our communities that provide healthcare services to the same population.
HLM: What have been the key elements of managing Priority Health profitably?
Cox: Managing utilization, managing our network to make sure we have people who are striving to provide a high-value service, and being price-competitive.
Most consumers pick health plans when they are not sick, and most consumers pick plans based on price. So, price is important, but when patients utilize health plans, you want them to be happy with the network, the services, the billing, and all the blocking and tackling at their health plan. We focus on all of that: making sure the coverage is affordable and it operates well, so our customers are happy.
University of Utah Health, a patient experience transparency pioneer, has raised its national patient satisfaction score from the bottom to the top quintile.
University of Utah Health used data sharing both internally and externally to lift its Press Ganey patient experience ranking from the 18th percentile in 2008 to the 84th percentile last year.
"We have more compassionate, connected care for patients, and a more satisfying workplace for providers where they get feedback from patients," says Mari Ransco, the Salt Lake City-based health system's director of patient experience.
She attributes the long-term gain to three milestones dating back 15 years:
2003: Patient experience data was shared internally with clinic leaders
2008: Patient experience data was shared internally with physicians
2012: Patient experience data was shared with the public on the UUH website
When the health system launched the transparency initiative in 2003, patient experience data shared with clinics revealed relatively basic, but extremely important, shortcomings, Ransco says.
The data showed patients were concerned about long wait times in waiting rooms and exam rooms, subpar courtesy at clinic front desks, and difficulty making an appointment. Addressing shortcomings at the clinic level was relatively easy compared to tackling issues at the physician level, she says.
"We started with the things that were easy—bureaucratic and system process failures."
The sharing of patient satisfaction data with physicians that started in 2008 was rolled out in two phases.
"Initially, it was anonymous, but you could see how your peers scored relative to you," she says. "Eventually, it was unblinded after a couple of years."
A key element of the physician transparency effort was a higher degree of access to patient experience data, Ransco says. For inpatient services, the health system started collecting data at the patient level that could be attributed to a particular physician.
The data was collected with Press Ganey medical practice surveys. The surveys were mailed to patients after their visits and included a visit identifier that tied the data to the health system's electronic medical record, which matched patients with specific clinicians.
Publishing patient reviews online
The decision to publish patient experience data and reviews online in 2012 was a giant leap for transparency at UUH, which posted $1.67 billion in total operating revenue for the fiscal year ending June 30, 2016.
Physicians were skeptical about making the information readily available to the public, Ransco says.
"It was very hard. Ultimately, we had a strong leader who pushed it, supported it, and believed it was in the best interest of patients and healthcare in general," she says.
Vivian Lee, MD, PhD, the UUH senior vice president for health sciences, has been a crucial transparency champion at the organization.
In addition to strong leadership, many UUH physicians were open to sharing patient experience data online because the data had been shared with growing intensity internally for a decade.
An external factor also helped physicians embrace publishing UUH-generated patient reviews online, she says.
"There were many other websites—Healthgrades and Vitals—that were publishing one or two patient comments about our physicians that were negative, and it was detrimental to those physicians' reputations."
Just as in 2008, new access to a wealth of data was a key factor in the decision to publish patient experience data online, Ransco says. In 2011, the health system pioneered Press Ganey's all-electronic survey, which generated more data at a faster pace.
Today, UUH receives about 3,000 patient experience surveys electronically per week, and the health system publishes both positive and negative reviews.
"Patients are typically satisfied with their healthcare experience," she says. "And when they don't have something positive to say, you can put that online because people are savvy about what they see online. It builds trust."
The health system has "exclusion criteria" that disqualify some reviews for publication online. These criteria include:
Reviews that reveal the identity of patients
Reviews that question a diagnosis or prescribed medications
Patients who criticize clinicians who are not their providers
For physicians who oppose reviews that appear online, there is an arbitration process to determine whether the reviews should be removed. Members of the arbitration panel are medical providers.
Lessons learned
Commitment to patient experience transparency is an ingrained value rather than a matter of employee training, Ransco says.
"We offer training when people request it and when people want it, but elevating patient experience has really been a cultural shift, with pressure within departments and within clinics that this is really something that is important to everybody."
At UUH, strong physician leadership has helped cement the culture change, she says.
"We have had a series of physician leaders who have talked about this authentically [and] not as a way to earn more market share, [or] to improve the overall standing of the university. They have shown what it means to them personally and how it fits with why they chose to go into medicine."
A systemwide initiative involving physicians, nurses, laboratory operations, and pharmacists has helped the nonprofit reduce its sepsis mortality rate.
OhioHealth has lowered the health system's sepsis mortality rate by 4.3 percentage points over the past two years through staff education and a new diagnostic tool.
"Our estimate is that we have saved about 250 lives," says James O'Brien MD, director of quality and patient safety at the Columbus-based health system.
Sepsis is the body's extreme reaction to an infection, which can result in life-threatening symptoms such as multiple organ failure. Annually, more than 1.5 million people get sepsis in the United States, with about 250,000 fatalities.
Starting in July 2015, OhioHealth has reduced sepsis mortality by educating staff members, utilizing a new diagnostic test, reducing the medication response time from hospital-based pharmacists, and creating a clinical culture that tolerates false diagnosis alarms.
Education effort
The effort required engaging thousands of health system workers about sepsis and highlighting an opportunity for care improvement, O'Brien says.
"A big piece has been making the case that this work is important to us as an organization by looking at the underlying data of what our baseline mortality rate was and how many people it was affecting across our health system," he says.
When OhioHealth launched the sepsis effort in 2015, the sepsis mortality rate was 24.3%. Last year, mortality in sepsis patients was 20%.
The health system’s wide range of hospital size, from critical access hospitals to its 800-bed tertiary care hospital, has been a significant challenge, O'Brien says.
Emergency care has been a focal point for the initiative, both internally in the health system's ERs and externally among emergency medical service workers, he says.
"We've worked through the Central Ohio Trauma System to get into the mindset of the emergency medical responders because they are significantly as likely to be transporting a patient to one of our hospitals with sepsis as with a heart attack or stroke."
New diagnostic tool
A new sepsis test developed at Salt Lake City–based BioFire Diagnostics has significantly reduced the laboratory time required to diagnose sepsis and narrow down the best antibiotic treatment, O'Brien says.
"It's gone from a day or more to a couple of hours."
The previous generation of sepsis tests requires a lengthy two-step process: A blood culture tests positive for sepsis, then the blood culture is "challenged" with multiple antibiotics to see which antibiotic would be best for treating the patient.
With the new test, once a blood culture tests positive for sepsis, molecular testing quickly narrows down the best antibiotics to treat the patient.
"It helps us to more rapidly identify the bacteria or organism that might be causing sepsis. Once a culture is positive for sepsis, this test helps us to very quickly get to which antibiotic will work best for the bacteria, and, just as important, which antibiotic won't work," O'Brien says.
Quicker to the bedside
Once an OhioHealth clinician has prescribed an antibiotic, pharmacists are expected to have the medication at the bedside in less than an hour, he says.
"In pharmacy, you need engagement with the medication safety pharmacist and the antibiotic stewardship pharmacist," he says "They are the folks who tend to be most in tune with our pattern of resistance to antibiotics and what is appropriate based on where the clinician thinks the patient was infected."
As has been the case with the health system's sepsis awareness and education campaigns, there has been no one-size-fits-all approach to boosting pharmacy response times for sepsis patients, and a crucial element of achieving quicker pharmacy reaction times has been including pharmacy representatives on Sepsis Improvement Teams that have been formed at every OhioHealth hospital.
Each team features about a half-dozen members, including the following:
A healthcare information technologist
A laboratory staff member
A pharmacist
A physician
A nurse
Forgiving climate for clinicians
Achieving rapid treatment for sepsis patients requires creating a clinical climate that does not penalize caregivers for "false-alarm" diagnoses, O'Brien says.
"We have to be really careful to understand that clinicians are doing a difficult task in trying to figure out what to do, because this is a disease for which there is no single test that says, 'This is absolutely sepsis,' says O’Brien. “They are making decisions with uncertainty."
Given directives from the Centers for Disease Control and Prevention and other organizations to avoid overuse of antibiotics, one of the keys to creating a forgiving climate for clinicians is being supportive of their diagnoses and medication decisions, he says.
"If you go back and beat up the clinicians for having given antibiotics when they were uncertain what the problem was, that's just unfair to them."
Adventist Health's new CFO discusses the challenges and opportunities facing the health system, including cost-cutting, expansion deals, and cuts to the 340B prescription drug program.
The new CFO of Adventist Health views cost-cutting in areas such as labor and supplies as the most daunting challenge facing the health system, with mergers and partnerships viewed as the most attractive opportunities.
Adventist has promoted Joe Reppert, CPA, MBA, to CFO of the Roseville, CA-based health system, which features 20 acute-care hospitals on the West Coast and in Hawaii. Reppert is succeeding Jack Wagner, who is retiring.
Reppert previously served as CFO of Adventist's Northern California region, where the health system operates seven hospitals. His experience also includes working as CFO of Tupelo, MS-based North Mississippi Health Services.
HealthLeaders recently spoke with Reppert, who officially begins his new role Feb. 1. Following is a lightly edited transcript of that conversation.
HLM: How will your system CFO role be different than the Northern California CFO role?
Regional roles are closer to operations and the daily challenges that come with managing hospitals and ambulatory businesses. You are closer to patient care…as opposed system roles in a corporate office. That is why rounding is so critical.
The move to system CFO will bring a new set of challenges. I will never step too far from operations, but I enjoy the strategic elements of healthcare finance such as balance sheet management, developing partnerships, and longer-term planning.
HLM: What was the most important lesson you learned from your experience as CFO of Adventist's Northern California region?
Reppert: In Northern California, Adventist Health is in the process of cementing business relationships with other healthcare partners. Most significantly is the acquisition of Rideout Health in Marysville, Calif., which will likely be effective this March.
Rideout is a … health system with revenues of $400 million. Its addition to Adventist will strengthen our geographic presence north of Sacramento. The addition of Rideout Health will enable more effective coordination of certain services and specialty care among our hospitals in that geography. That circles right back to better care for our patients. As a result of this new affiliation, other partnerships are developing for further expansion of services, locations, and covered lives.
Relationships with other providers, payers and outside resources should be repeatable in other markets.
HLM: In 2018, what are the primary financial challenges for Adventist?
Reppert: Some of our health system executives and I recently attended a national healthcare conference to hear presentations from several prominent health systems. A consistent theme among most was the imperative for cost reductions.
We will be going methodically through expense line items. Typically, the larger opportunities lay with labor and supplies. Those are the expense categories where we have the greatest influence. Wherever there are opportunities for efficiencies or labor management, we will be turning those rocks over.
We will push for more effective management tools and relentless accountability throughout every operating unit and department, which is critically important to achieve the panacea of low-cost/high-value.
We work with Premier on the [group purchasing organization] side, and we have several opportunities and projects under way right now to not only reduce our supply cost per unit, but also to reduce utilization by working with our medical staff on physician-preference items.
Every hospital has some rent costs and lease costs, which are recurring expenses. If you have the time, you can turn that rock over to see whether the expense is necessary and whether it is something you can possibly eliminate.
Everyone in this business also knows the regulatory-related challenges that affect hospitals. The 340B reductions alone will cost Adventist Health $5 million, which is a negative annuity that needs to be made up elsewhere. This specific change relates to a 22.5% reduction in payments to hospitals for pharmaceuticals.
HLM: That covers expense reduction, but what will Adventist do to grow the revenue side this year?
Reppert: Adventist Health will grow in scale. One example is with our newly expanded business relationship with Cerner to quicken the EMR optimization cycle and revenue cycle performance. There is accountability to deliver results leading to increased yield and cash acceleration. Reducing the billing cycle and further improving clean-claim rates are opportunities within our grasp.
Additional affiliations with other acute and post-acute care providers will likely continue into the future.
HLM: What are the key financial metrics for you and your team?
Reppert: The fundamental financial metric is [earnings before interest, taxes, and amortization] performance. Our EBITA percentage is fundamental and we stay very focused on it.
Underlying that overall metric are certain expense metrics, such as labor metrics and supply costs. We look at worked hours per unit of service and we look at supply costs as a percentage of net operating revenue.
The health system's metrics are not just financial. We also have a balanced scorecard. Our managers are accountable for patient satisfaction, quality indicators, and employee engagement.
HLM: Adventist has post-acute care facilities, including hospice. What are the primary challenges of integrating acute care and post-acute care facilities?
Reppert: As we transition into capitation, the financial incentives align appropriately. Adventist Health currently manages nearly 200,000 capitated lives. Most of our acute-care operations are across a wide geography, so aligning all post-acute care services is a challenge but worthy of cementing further.
This is partially addressed through program development within our hospitals, home health agencies and physician practices. In some markets, we affiliated with partners that have distinct experience and expertise in programs for seniors. The result has been the development of senior communities, some of which are adjacent to our hospital campuses. Those communities offer housing for seniors as well as a complement of services that add to the continuum of care such as home health, rehabilitation, and memory care.
Stepping up efforts to address the opioid crisis, Northwell Health expanded 'universal' drug screening to its children's hospital.
As part of efforts for early detection and diagnosis of opioid addiction, Northwell Health has expanded alcohol and substance abuse screening beyond adults to include patients aged 12 to 18 at Cohen Children's Medical Center.
Expansion of the addiction screening last week is part of the New Hyde Park, NY-based health system's commitment to help all patients address substance-abuse disorders, says Sandeep Kapoor, MD, director of the health system’s Screening, Brief Intervention and Referral Treatment program (SBIRT).
Northwell conducts SBIRT screening for every patient at all of the health system's emergency rooms and primary care practices, he says. "It's been a universal approach."
SBIRT is a key component of Northwell's response to the opioid addiction crisis because of the importance of early detection and diagnosis, says Joseph Conigliaro, MD, chief of general internal medicine at the health system. "The whole idea behind SBIRT is you can get at addiction early as opposed to getting it late, when the horse is out of the barn."
SBIRT, which Northwell launched in December 2013, features self-reported screening for alcohol and substance abuse with evidence-based tools. Northwell clinicians have been using two SBIRT evidence-based tools at primary care practices and emergency rooms for adults, and they are using one screening tool for children.
Self-reported screening features patients responding to screening-tool questions. For example, adults are screened for opioid and other illicit drug use with the Drug Abuse Screening Test, which qualifies and quantifies prescription and illicit drug use, then risk-stratifies patients.
At Northwell, Kapoor says brief interventions are the primary focus of SBIRT for patients detected with possible opioid addiction:
The essential element of the brief intervention is a conversation that engages the patient about their opioid use. The conversation features four pillars of motivational interviewing: compassion, acceptance, partnership, and evocation.
The interviewer seeks to build rapport and trust, then provides feedback on the screening with the patient's permission.
The conversation serves as a starting point to help the patient gain insight and self-identify any consequences related to their opioid use.
At the end of the conversation, the interviewer determines whether the patient is ready and willing to make a change, then helps the patient formulate a plan that could include referral to specialty care.
"It's a nonconfrontational conversation during a clinical visit—either in an emergency room or a primary care office," Kapoor says. “Even though it is busy, you pause and speak with the patient to better understand where they are at with their substance use."
The key to implementing SBIRT at Northwell primary care practices has been integrating the program into clinical workflows, Conigliaro says, noting that efforts with medical assistants and nurses helped screening for addiction become essentially another vital sign.
Northwell's effort to implement SBIRT in both the ER setting and at primary care practices is a significant achievement, Conigliaro says. "This in itself is a measure of success, demonstrating organizational awareness and acceptance that substance use needs to be handled as any other disease process."
The universal nature of SBIRT screening at Northwell's primary care practices and ERs is also crucial, he says.
"We screen everybody. We don't try to pick out people who are more likely to be addicted. So, if you are a 75-year-old nun, you are going to get screened for alcohol and drugs."
Opioid Crisis Task Force
Another addiction initiative at Northwell is starting to roll out new programs.
Launched in 2016 with six members drawn from interdisciplinary fields, Northwell's Opioid Management Steering Committee is developing a "battery of solutions" to help address the opioid crisis in New York, Kapoor says.
The steering committee has four focal points:
Limiting the supply of opioids
Raising awareness of opioid addiction
Identifying and managing the dependent population
Treating the opioid-addicted population
Several steering committee work groups have been formed:
Community and school-based outreach
Pain management
Data mining to help monitor and evaluate Northwell's opioid-addiction programs
Addiction protocols for standardizing inpatient treatment
Practice guidelines for opioid-medication prescriptions
Emergency medicine not only to identify patients who are addicted to opioids but also to start treatment in the ER before handing off patients for specialty care
Currently, two of the steering committee's pilot programs that focus on the safe disposal of opioid medications are being expanded.
One pilot program started with a safe-disposal receptacle for medications being installed in the main lobby at Southside Hospital in Bay Shore, NY. A contract was recently signed to have the receptacles installed at other Northwell hospitals, Kapoor says.
The other medication-disposal pilot program features Northwell's commercial pharmacy partner, Vivo Health Pharmacy.
Starting in November, all Northwell opioid medication prescriptions filled at a Vivo Health Pharmacy have gotten a special sticker on the bottle cap. The sticker has a message for patients, advising them that if they have any unused medication they can call the pharmacy, which will mail a safe-disposal pouch.
The pouches, which contain a neutralizing agent, can be used to dispose as many as 15 pills. Patients place pills in the pouch, add a few drops of water, then throw the pouch in the trash.
The safe-disposal pouches have been popular with patients and the program is expected to expand when new Vivo Health Pharmacies open, Kapoor says.
Opioid Addiction Treatment
In 2016, Northwell provided substance-abuse disorder services to 6,000 inpatients and 90,000 people in outpatient settings, says Jonathan Morgenstern, PhD, assistant vice president for addiction services.
At Northwell, which has five tertiary hospitals, 10 community hospitals, three specialty hospitals, and four affiliated hospitals, Morgenstern says most opioid-addicted patients follow a three-step trajectory:
Inpatient detoxification for three to seven days to withdraw from physical dependence on opioids, usually with the assistance of medication such as Suboxone.
Inpatient rehabilitation for 10 to 14 days. "Typically, when a patient comes out of detox, they are not experiencing withdrawal, but they are in a vulnerable and somewhat shaky state. … They need a protected environment and therapy," Morgenstern says.
Outpatient services for three to six months, including medication and a combination of individual therapies to help patients transition from a protected environment back into their communities.
Even though treatment for opioid addiction can take months, most insurance plans cover the treatment and there is funding for uninsured patients, Morgenstern says. Under the Patient Protection and Affordable Care Act, substance use disorders treatment, including opioid addiction care, is considered an essential benefit that commercial plans must cover. Also, many states provide direct subsidies to SUD treatment programs to fund treatment for uninsured patients.
The nonprofit network reversed an upward trend in claims denials, with the month-to-month denial rate reduced to as little as 1%.
Since 2012, Orlando Health has conducted concerted efforts inside and outside the health system's revenue cycle team to decrease claims denials, which were trending above 5% on an annual average basis.
"It was a high-priority project because our denials were increasing," says Bridget Walters, corporate director of enterprise patient access.
The claims-denial prevention efforts, which are ongoing, have reduced claims denials significantly, with monthly claims-denial rates as low as 1%, she says, adding the average annual denial rate is about 4%.
Coordination and Accountability
One of the first claims-denial initiatives Orlando Health launched was the creation of a denials management team with existing staff members that focused on claims denials enterprise-wide, including the health system's seven acute-care hospitals.
Walters says the denials management team featured top-notch employees drawn from three areas at Orlando Health facilities: collectors, billers, and nurses.
"We had a total of 14 individuals on the team who were star performers in their areas," she says.
The primary focal points of the denials management team, which met on a weekly basis, was denials prevention and large-claim denials.
Once the denials management team started identifying trends, Walters says it took several systematic actions to prevent claims denials:
Worked with department executives to incorporate claims-denial prevention mechanisms in workflows
Conducted "road shows" to meet with nurses and other key staff members at the health system's hospitals and clinics to discuss claims-denial trends and collaborate on claims-denial prevention
Tracked claims denials as avoidable or unavoidable, then shared those categorizations with all affected areas such as coding, revenue integrity, physician practices and scheduling
Educated the clinical team on the medical necessity guidelines for inpatient admissions
With the health system's denials prevention effort matured and optimized, the denials management team has shrunk to seven members and meets monthly. The team is staffed with patient-access managers, who are not only continuing the claims-denial prevention activities of their predecessors but also closely supervising registration staff to prevent patient-access-related claims denials.
Educating the registration staff about the complete revenue cycle is crucially important, Walters says.
"We connect the dots so they understand the impact on the bottom line. Their work can affect the patient experience, the accounts receivable days of patient accounts, decreasing our bad debt, and reducing the cost to collect."
In addition to the denials management team, Orlando Health has been gathering together a broader array of executives and clinical staff to prevent claims denials. In 2012, these gatherings were called task force meetings, which were held as frequently as weekly. Currently, these meetings are held on a quarterly basis. "We review the dashboard of each facility to see their denials and what their top trends are in denials," Walters says.
In addition to the denials management team, the quarterly meeting features an array of interdisciplinary staff members, including:
Hospital CFOs
Corporate and facility revenue cycle staff
Managers from multiple departments, including case management, information technology, and rehabilitation services
Working with Payers
Thanks to this work, Orlando Health generates cleaner claims and has multiple mechanisms to hold payers accountable to process claims on a timely basis.
"We have many checks and balances for compliance, from our registration all the way through to our billing," Walters says.
One example is ensuring compliance with the Two-Midnight Rule. The Medicare regulation states patient hospital stays that span less than two midnights are generally inappropriate for categorization as an inpatient stay and payment under Medicare Part A. Some "inpatient-only" procedures qualify patients for inpatient status regardless of length of stay.
"We make sure that we educate the physicians and clinicians to understand the complete process and inpatient-only procedures," she says. "We are always making sure that documentation is getting audited."
When claims are denied, Orlando Health, which posted $2.5 billion in net patient service revenue for the fiscal year ending Sept. 30, 2016, closely examines the 835 electronic data interchange documentation from the payer. The 835 EDI provides payment and remittance advice from the payer, including billing codes.
"It takes a team effort. We will get the billing manager involved. We also have a cash receipts manager who understands the 835 inside and out, and we will bring in one of our denials experts," Walters says.
After one payer denied several emergency room visit claims, an 835 EDI review showed the payer had made a coding error, she says. Once the error was identified, the payer updated its system and reprocessed the claims.
Effective contracting forms the basis of productive and fair relationships with payers, Walters says.
For example, Orlando Health has established joint operating committees with several payers. These committees bring together Orlando Health and payer staff members for face-to-face meetings every other month to find out who is accountable for claims denials and to resolve those problems, Walters says.
The health system's representatives on the panels include patient access, patient accounting, managed care, denials management team members, a credit balance manager, and case management. Payer representatives include a director of case management, managed care, contracting officers, and analysts.
"When you sign the contracts, you need to make sure the contact mechanisms are in there. You need to have the joint operating committee meeting in there, and who is going to be present and the expectations," Walters says.
In addition to spelling out the parameters for cooperation, contracts with payers need to have provisions to compel corrective action, she says.
"Everything falls on the contract, including getting advance payments. If a payer's performance is not good, you can hit them in the pocket."
Indiana's largest health system has used a 13-fold increase in its financial-adviser staff to drive down the number of uninsured patients by helping them acquire health insurance.
IU Health has slashed the percentage of gross patient revenue that comes from self-pay patients in half over the past six years in large part by increasing the health system’s financial-counselor ranks from 12 to 158.
In 2012, self-pay as a percentage of gross patient service revenue at the
Indianapolis-based health system was 5.46%. In 2016, self-pay had plummeted to 2.85%.
In large part, the counselors help eligible patients navigate a confusing array of possibilities to find a commercial insurance product or government program for which they qualify.
"Ideally, you are reducing the number of self-pay patients and converting more to an insured product, an insured plan, Medicaid payer plans, or Marketplace payer plans," says Angie Church, program manager of individual solutions at IU Health.
At IU Health, the Individual Solutions Department is part of the health system’s revenue cycle corporate division. Its 158 individual solutions senior associates must be state-certified as financial navigators, and they work in several settings across all 15 of the health system's acute-care hospitals, including:
Emergency room and inpatient facilities
Business offices where uninsured patients are screened for coverage options prior to hospital services, with the screening conversations held via phone calls or at the business office
“Back-end” billing offices, where financial advisers help patients try to qualify for coverage after receiving services
Qualifications and Training
When hiring new individual solutions senior associates, compassion is an essential quality that candidates must be possess because the financial advisers collect sensitive personal information, Church says.
"We are getting the medical history, the household size, and family member information. To build a relationship and trust with a patient, where they want to open up to you, there is a certain type of personality that is well-suited to the position."
Communication and assessment skills also are crucial, she says.
"They need to be agile. They have to be able to quickly assess the patient's eligibility, circumstances and what the patient may qualify for."
Once financial advisers are hired, they undergo pre-certification training for the state department of insurance navigator license examination. IU Health trainers guide new hires through the pre-certification course, including about 500 pages of study material, Church says.
Consumer assistance basics such as conflicts of interest, confidentiality rules, and reporting requirements
Medicaid basics and Indiana health coverage programs, including benefit packages and available services, Medicaid eligibility requirements, and state-based assistance program terminology
Health insurance basics and the federally facilitated Marketplace, including open enrollment periods and special enrollment periods, the application process for health plans obtained through the Marketplace, and minimum essential coverage
IU Health, which posted $6.2 billion in total operating revenue for the2016 fiscal year, also trains its financial advisers to use an in-house healthcare-coverage eligibility tool.
"The tool takes the patient from initial eligibility determinations to determining their eligibility results, then takes the patient all the way through the application process, being enrolled and, hopefully, to being approved for active coverage," Church says.
Working with Patients
Best practices for having financial conversations with patients involve both preparation and good judgment, she says.
"The scripting helps start out the conversation with the patient, then the navigator uses best judgment to take it from there."
Much of the scripting is related to the different coverage plans that are available.
"We are constantly working to make sure it is up to date," she says, noting the significant effort needed to stay abreast of changes to Medicaid, Medicare and other government programs.
For hospital patients who are not seriously ill, individual solutions senior associates start conversations in a manner that helps build trust, then try to determine whether patients qualify for healthcare coverage, Church says.
These conversations begin with an introduction, with the financial adviser explaining the navigator role. Patients also are told approximately how long the interaction will take and what to expect such as the eligibility screening process.
For seriously ill hospital patients, financial advisers often enlist members of the clinical care team to help collect and process information, she says.
"We work closely with case management, care managers and social workers. For patients who have been in and out of the hospital for multiple treatments, being able to work with the case management team is beneficial because they often have an existing relationship with the patient."
Working closely with the case management team can ease the collection of documents, Church says. The case management team often helps secure physician signatures on financial forms and connects financial advisers with family members who can get copies of documents.
In all cases, financial advisers strive to improve the patient experience, she says.
"After that initial introduction, [patients feel] a sense of relief because you can help them through the process," Church says.
Dignity Health's physician group cut patient increased cash collection and cut patient bills in accounts receivable.
A revenue-cycle initiative at a California-based physician group has boosted the organization's finances, including a 20% decrease in accounts receivable over 90 days and an increase in cash collections to 108% over budget.
Dignity Health Medical Foundation’s affiliated medical groups serve as the primary employment model for Dignity Health in California, with more than 1,000 clinicians. San Francisco-based Dignity Health operates 39 hospitals in California, Arizona and Nevada.
In January, DHMF sought to reverse downward trends in accounts receivable, cash collection, and earnings before interest, tax, depreciation, and amortization. In response, the organization launched an effort that focused on accounts receivable management, charge integrity, vendor strategy, and clinical documentation.
Accounts Receivable
One of the primary goals of DHMF's revenue-cycle initiative was to improve accounts receivable performance without relying on increased effort—and expense—at accounts receivable vendors. This goal was met by increasing staff time in the DHMF central business office created mainly with overtime hours.
With the additional staff hours, AR was assessed on a weekly basis. The assessments targeted several classes of accounts that had aged beyond 120 days, including these:
Rejections of claims over $1,500 due to medical record requests
Claims rejections for surgeries and infusions due to missing information such as operative report notes
Government claims that could be collected potentially quickly, such as Medicare claims
High-dollar recurrent patients
Commercial payers with a history of paying relatively quickly
DHMF focused on accounts aged beyond 120 days for two reasons, says Diane Butler, a director at Chicago-based consultancy Navigant, which helped implement the physician group's revenue-cycle initiative. First, the difficulty of collecting accounts increases significantly after 120 days. Second, AR aged greater than 120 days is customarily "reserved," with organizations setting aside cash in the event of failure to collect and eventually transferring the outstanding balance to bad debt.
The AR effort has generated significant gains, says Christopher McGoldrick, DHMF’s chief financial officer. "When we began this initiative, approximately 50% of our accounts receivable was less than 90 days. Now, it represents 70%."
DHMF, part of a health system that is slated to merge with Englewood, Colo.-based Catholic Health Initiatives, has set a goal of 85% of AR at less than 90 days, he says.
Improved AR performance coupled with enhanced cash collections were better than budgeted levels and more than offset increased spending on CBO staff overtime, McGoldrick says.
"We had a 300% return on effort."
Charge Integrity
Before a physician's services can be billed to a payer, the charge capture process must be completed. Charge capture identifies the services rendered as well as patient-encounter information such as patient name, medical record number, date of service, and where the patient was seen.
To optimize its charge-capture processes, DHMF, whose parent company posted $12.6 billion in 2016 operating revenue, took several actions:
Developed a management report for missing and pending charges to alert clinic leadership about delays between time of service and billing of service
Modified the coding staff review process to focus on claims with higher complexity because of the proven track record of clinicians coding patient encounters with lower complexity
Decreased the time for finalization of a charge and clinician sign-off
The coding staff focused on high-complexity charges as a crucial part of DHMF's charge-integrity effort, Butler says.
"The coders were looking at every single charge that came through, which was a huge piece of business. Based upon experience, we knew that some charges did not need to be reviewed, especially [evaluation and management] codes at the lower levels," she says.
E&M codes range from Level 1 to Level 5. Butler says clinicians tend to code correctly for the lower-level codes: Level 1 to Level 3. However, clinicians have shown less accuracy when coding Level 4 and Level 5 services.
At Level 4 and Level 5, the code reflects intangible services such as medical decision-making and the complexity of the patient's status.
“Experience has shown that providers are more likely to undervalue these less tangible services and choose a code that does not accurately reflect the complexity of the patient's status or the decision-making employed by the provider," Butler says.
Vendor Strategy
"There was a dependence on vendors that had become automatic," Butler says. "What DHMF has now is a prospective look at where they have the internal talent to manage claims, and where there are claims that are so small in volume that they don't have the expertise—that's where they look to bring in vendors."
For "niche" claims with small volumes, vendors often have expertise in areas such as coding that DHMF does not have in-house.
Based on this vendor-spend strategy, DHMF renegotiated some contracts to drive cost savings, McGoldrick says.
For example, DHMF has been able to lower accounts-receivable costs by changing the timing of when some claims are sent out of the organization to a vendor for accounts-receivable management. Under one original contract, claims were placed with an external AR vendor at 120 days from the date of service. Under the new contract terms, claims are sent out to the vendor 120 days from the date of posting the charge.
This contractual change has resulted in keeping aging claims in-house about 10 days longer.
"We recognized that they were aging out and being placed with the vendor, when, in fact, we had done the lion's share of the work and all we had to do was further pursue payment," McGoldrick says.
Decreasing reliance on contract-labor coders also has generated significant cost savings, he says. "We were paying about 300% more per hour to hire contract-labor coders than to have coding in-house. So, we have an initiative to bring in many of our coders."
Clinical Documentation
Physician engagement, training and coding oversight were the main components of DHMF's clinical-documentation improvement efforts.
Financial messaging was the key element of physician engagement, McGoldrick says, with clear communication that the central business office needed accurate clinical documentation including physician charts to generate service charges and compensation for clinician services.
"For them, it was a matter of compensation. For us, it was a matter of revenue recognition."
A vendor provided peer-to-peer clinical-documentation training for DHMF physicians.
"Doctors heard from other doctors on how to code their patient encounters appropriately. They were already doing the work, and they just needed to document it in order to get the appropriate credit," McGoldrick says.
"Coder intervention" is an essential part of clinical-documentation oversight, he says. These interventions feature coders bringing a sampling of notes to a clinician, who is shown how the notes could have been modified to reflect the appropriate level of service and medical decision-making.
From March 2017 to this month, DHMF's charge-capture and clinical-documentation efforts have significantly reduced the lag between time of service and the generation of a service charge, he says.
In March, the lag was 22 days; now, the lag is 10 days.
Editor's note: This story has been updated to more accurately describe the relationship between Dignity Health and DHMF physicians.
National urology association estimates its alternative payment model could save Medicare $51 million in five-year period.
The first urology-specific alternative payment model for Medicare beneficiaries has reached a key milestone in the U.S. Department of Health and Human Services approval process.
If PTAC gives a favorable recommendation of the APM, the office of the secretary of HHS would make the final approval decision.
The payment model was crafted by the Large Urology Group Practice Association, with assistance from West Palm Beach, Fla.–based Integra Connect and Salt Lake City–based Myriad Genetics.
According to LUGPA's proposal for the APM, a key goal of the payment model is to boost financial support for active surveillance that monitors patients. Active intervention is 2.5 times more expensive on average than surveillance, with the cost difference more than $20,000 per episode of care, LUGPA says.
Active interventions for cancer localized to the prostate include radiation therapy, prostatectomy, and hormonal therapy. LUGPA says interventions put patients at risk of several negative outcomes such as diminished sexual function, urinary incontinence, bowel dysfunction, and urinary irritation.
LUGPA's APM proposal contends that the Medicare fee-for-service payment system is skewed in favor of active interventions for prostate cancer patients. "This has created a misalignment of incentives which results in decision making that promotes [active intervention] for men with localized prostate cancer—data suggests that some of these patients are appropriate candidates for active surveillance."
In 2015, about 63,000 Medicare fee-for-service patients were newly diagnosed with localized prostate cancer, and 77% of those men received an active-intervention treatment, according to LUGPA.
The LUGPA APM features yearlong episodes of care:
An initial 12-month episode of care, beginning with a prostate biopsy and a cancer diagnosis, for men receiving active surveillance or active interventions.
Subsequent 12-month episodes of care for men who remain on active surveillance at the end of an initial yearlong active surveillance episode.
The APM includes a two-part payment model:
A $75 monthly care management fee for initial and subsequent active surveillance episodes capped at $900 per episode.
A performance-based payment for enhancing utilization of active surveillance compared to a historical period.
LUGPA estimates its APM would save Medicare millions. "Medicare claims data suggest that the LUGPA APM could reduce expenditures by $138 million in five performance years, with Medicare saving approximately $51 million."
Editor's note: This story has been updated to include entities that assisted in the crafting of the payment model.
