Operationalizing New Transparency Requirements Katherine H. Murphy, FHAM, CHAM

1. 46th Annual Educational Conference & Exhibition Patient Access:   The First Connection to a Lasting Impression September 23, 2014 Operationalizing New Transparency Requirements Katherine H. Murphy, FHAM, CHAM VP Revenue Cycle Consulting, Passport/Experian Health

2. What Patients Want • Designing Access is the Most Important Initiative You Can Undertake • Expertise from Y-O-U! • They do not want to work hard for Access or Information (“If you make me work hard to do business with you I will go somewhere else”) They want to be W-E-L-L Paul Roemer, VP Clinovations/Pale Rhino Consulting

3. Transparency - Defined • Generally implies openness, communication, and accountability. Transparency is operating in such a way that it is easy for others to see what actions are performed. • “The perceived quality of intentionally shared information from a sender". • Infusion of greater disclosure, clarity, and accuracy into their communications with stakeholders

4. Can we make a complicated process simple? Doc, What is Healthcare Transparency? I think we need to schedule another appointment…

5. Today’s Lesson • Transparency Overviews • Best Practice • Industry Best Practice recommendations • How to follow the recommendation • Provider Journey • Provider success story: The start up & current state • Transparency future state • Transparency Gone Wild! (Going the Extra Mile) • Technology • Patient Engagement • How to drill down estimates and be closer to the truth!

6. The Way We WERE So…Lola,what did you say a “dial tone” was for?

7. The Patient Balance Death Spiral PROJECTED $732 Breakdown of U.S. Healthcare Consumer Responsibility U.S.$ billions, estimates $420* $515 $450 -- CONSUMER TO PROVIDER -- $265 -- CONSUMER TO PROVIDER -- $250 $312 $200 $250 -- CONSUMER TO PAYER -- -- CONSUMER TO PAYER -- 2007 2015 2005 *Source: 2007 & 2009 McKinsey analysis

8. If only Price Transparency was this easy!

9. I know everyone will be excited about new ways not to get paid

10. Transparency can occur whenever there is communication between any two of: • Insurer • Provider: hospital/physician/Patient Access & Patient • Primary Care Physician • Specialist • Ancillary testing facility • Post Acute Care • Nursing Home • Home Health • Family Caregiver • Pharmacy

11. Today Transparency across the continuum! (not related to any one episode) New Paradigm– Pop Health Mgmt Old Paradigm – episode of care • Office Visit… • Scheduling…Testing… • Admission/Reg… • Discharge… • Billing…for svc you provided • Payment • Bill me • Connected to EMR’s/ACOs • Confirm appt / Pt Arrival/ Results • PreService Clearance prior • Phys office + specialists + Others • Billing=combination of providers • Bundled Payments • Pay me .

12. Moving from Volume to Value: What’s Different? Degree of Transparency!

13. So it shouldn’t be a surprise that… • Notice to Patients Required for Outpatient Facility Fees • Posted: 24 Apr 2014 11:36 AM PDT (Effective Oct. 2014) • The Connecticut House of Representatives responded on Wednesday to medical billing concerns patients expressed over undisclosed and unexpected facility fees by unanimously passing a bill that requires notice. Many patients expressed that the additional charges were a surprise when they received their bill. The legislation now moves to the state Senate for a vote. The charges, often referred to as "facility fees" are charged to patients by medical offices that are owned by hospitals for outpatient care. These fees are separate from doctor fees. Facility fees range from several hundred to thousands of dollars.The bill to require notice to patients about fees possible extra charges for outpatient care at medical offices owned by hospitals. The bill specifically requires that patients with scheduled appointments at medical offices where facility fees are charged receive notice about the fees in plain language before they receive treatments scheduled so long as the appointment is scheduled at least 10 days in advance. If the exact nature of the services or insurance coverage is unknown the patients would be provided with an estimate based on typical charges at the facility. Notice for patients receiving emergency care would need to be delivered as soon as practicable after the patient is stabilized. The bill does not impact the offices' ability to charge facility fees. Other provisions in the bill are include requirements that the office prominently displays that the facility is connected to a hospital, what hospital the office is affiliated with, and states that the patient may incur higher charges than if they were treated at a facility that isn't hospital-based.

14. Massachusetts Chapter 224 The law aims to control health care cost growth through a number of mechanisms, including the creation of new commissions and agencies to monitor and enforce the health care cost growth benchmark, wide adoption of alternative payment methodologies, increased price transparency, investments in wellness and prevention, an expanded primary care workforce, a focus on health resource planning, and further support for health information technology

15. New BusinesseSinvestors are drawn to the concept of price transparency, with shares rising 139 percent on its first day of trading. • Castlight is helping patients select the best price, and quality service. Are you ready? • If you’re not offering competitive prices and high quality outcomes employers and patients may start taking their business elsewhere. Wall Street appears to have casted their vote in favor of patient consumerism.

16. Canary – Infection Transparency “Using the breath biomarker, we can pick up the body getting ready to fight infection ... even before the patient is showing signs,”

17. SharePractice - New way to rate treatment? Yelp for Doctors?over 5,000 health care providers using the app

18. TapCloud

19. What are we tasked with? And How do we accomplish

20. Enterprise Transparency: Provision of care • Provider organizations will have clear policies on how to interact with patients with prior balances choosing to have elective or non-elective procedures. They will also have cleardefinitions for elective and non-elective procedures. These policies will be made available to the public. • Brochures, Website, all documents • Patients do not speak ABN, MSP, elective, In from Out! • Lasix vs Furosemide

21. Best Practices for Transparency • Have defined processes for all patient types: EMR – OPT – INPT – Pre • Discussion with Participants - not to disrupt workflow • Patient Share Responsibility / Estimate / Navigation Counselor • When: Pre/Post Service, Emtala, Walk-ins • Include Financial Screening along with Estimation * Use of consumer data * Toll Free number / Business Cards • Appropriate Discussion Settings & Script • Pre – Point - change in discharge process (fast pass?)

22. The Best Payment Promise Providers must… • Know who is in front of them. I.D. your patient – Keep patient SAFE & STOP RETURN Mail • Define the medical language in CONSUMER language • Have the correct insurance and benefit information. • Tell patients what they will owe at the time of service. • Enroll for Financial Assistance before rendering service. • Extend hospital charity to those who qualify. • Securely accept payment upfront for smaller balances. • Extend payment terms and fundraising options for larger balances. Every patient leaves knowing what they owe & how their services will be paid for! Excellence in Patient Financial Triage includes determining the Patient’s Preferred method for future Communications!

23. Who, Where, When? How easy is this for You? • Prior Balance Discussion • Balances across their continuum of care • Payment plans tailored to successful collection • Summary of Care Document • Annual Training of Registration – MSP, Collections, Payer Skills, Industry trends & updates

24. Measurement/communication • Collections / accuracy • Consumer satisfaction Surveys / real time • Host Focus Groups • Define Medical and Legal terms and provide access to them – See handout • Access success – Reduction in Dups, return mail & patient complaints, cancellations, no-shows • Increase – patient satisfaction scores, collections, employee satisfaction, positive internal relationships

25. Pushing the Right Buttons at the right time!

26. Negotiation Skill Training! • Display Confidence! • Be sensitive to the situation (emotional intelligence) • Be aware of cultural differences • Be humane, respectful and honest • Determine what leverage you have • Be realistic – understand the strategy and policy • Hire with these traits in mind

27. Lisa Tozier – St Joseph’s Story

28. Provider overview • Faith Based organization • Bangor Maine, Population 33,000 • St Joseph Hospital/Covenant Health System • Licensed for 112 beds • Self pay portions increased volume • Transparency & collection = new concept to patients • Delicacy in rolling out the changes and keeping within the mission

29. Patient Access/Revenue Integrity Manager • Manage the day to day operations for a Patient Access staff of 30 • Responsible for pre-reg, pre-cert, face to face reg and the ED • Manage the day to day operations for a Reimbursement staff of 3 • Responsible for managing charging throughout the hospital • Responsible for managing RAC, MIC, ADR and 3rd party audits • Liaison between the revenue cycle departments • Lead our Revenue Integrity Team • Spend 2 hours a week working with Patient Accounts solving issues • Spend 2 hours a week working with IS to ensure our revenue cycle computer systems are running correctly. • Lead implementation coordinator for all revenue cycle software • Maintain security for revenue cycle software programs • Responsible for the overall maintenance of the hospital’s chargemaster • Responsible for the expanded proration file

30. Benefits offered • Patient discounts from Providers • Financial Counseling Services • Card give to patient for Counseling hours • Establishing a Physical Space and staffing in the ED (certified counselor for HIX) Key Factor: Physical Space

31. Centralized & Decentralized oversight • Challenges • Training staff – 2 day with pre-reg staff and time with education trainers • ipad swipes / kiosks (where, which patients) • Outcome: More Transparency = shorter throughput

32. Communication - Liaison • Role connectivity between rev cycle, ancillary and I.T. departments to make process improvements • Automated process developed allows for Patient Access + PFS transparency. • Dedicated price estimation line and dedicated Financial Counseling line. • Keep it Simple - allow for Patient Engagement via patient portal, smartphones etc

34. Tackling Pricing Transparency • CDM • Historical Claims Data • Complex Contract terms • Manipulating pricing/co-morbidities • Correct Insurance plan codes • Rich Eligibility Data(Web, COB, HIX) • Carve outs • Ability to Pay • Propensity to pay • Collection process • Payment plan creation • Portal payments • Ability to explain calculations OUCH!

35. #1 :Support from Internal resources • ED and ancillary staff • Revenue Cycle Departments • Senior Management – on board • I.T.! • Working to budget much needed resources • Provider owner physician practices & entities • All staff physicians • Their Office staff • Marketing Educating consumers and supporting the vision is everyone’s job.

36. Quality Management – it’s what’s upfront that counts! • Without quality data you cannot be transparent with any sense of accuracy • Scrub accounts upfront • Auto scripting corrections means less rekeying and less chance for error. • Snapshots of electronic trx and info kept for audit trail • Reports! Communicate Success! Ya Gotta Be a Team Player

37. Goals for Transparency implementation • ONE Integrated platform – Touchless processing! Lisa joined Exp/PP • Work queues • Address verification USPS and Validation • Q.A. • Eligibility Verification • Scripting address & eligibility corrections/carrier codes • Medical Necessity • Automated Pre-Authorizations • Patient Liability Estimator • Payment Processing • Patient Portal & results tracking/reporting • Patient Kiosks & m devices (Pt check-in to streamline experience) 2015 – Financial Screening, Automated Charity apps • Automated Physician Orders – legible/screened/ kick off! • PreClaim scrubber and new claims processing solution • New statements to better communicate bill, programs, even coupons!

38. Future state • Kiosks in all areas • Scrubbing tool integrated with PFS • Patient Portal for test results/appts and financial and clinical communications • Automated PreAuth • Work closely with Provider owned practices to move processes even farther to the front of the patient experience • Physician liaison role to assist with the physician office relationships • Automated phone calls to encourage pre-processing

39. Vendor Selection Customer Support vendor vendor

40. COB SMART – Wow!

41. Include/Exclude?(Out of Pocket Options)

42. Drilling Deeper into pricing Combined Estimates • Use Historical Claims Data • Use CPT & ICD codes • Cross walk CPT to ICD • Combine Hospital & Physician liabilities • Consider specific physician and location • Establish high, average, low pricing • Adjust specific line items • Access readiness for ICD10 in automated tool

43. I’ll splane our silver burger plan

45. Eligibility HIX Response

46. How can you deny me today? • Grace Period = claim denied? Claim paid? • Collect from patient & refund later? • If the deductible hasn’t been met can’t you collect payment anyway? It is not covered right? • If the patient pays the premium…does this payment automatically trigger a payment to the hospital? • Will the hospital have to track and monitor denials to rebill? • How must administrative cost is there?

47. how do you make this possible? Benefit data Contract Data Financial Triage & PIV Accurate Data & Denial Prevention Skills & Patient Satisfaction + CHANGE Cashiering Tools Payment Estimate Through Technology!

49. Transparency Gone Wild!

50. Sometimes Transparency is well… Opague • Disclaimer verbiage • Communicate typical variances up front • Additional amount due vs. refund