With Election Day behind us and the upcoming Presidential election in 2020, Medicare for All is one hot topic. Continue reading “Eliminating Medicare Denials is More Important than Ever!”
Category: For Hospitals & Physician Groups
Stay informed on the latest industry news, best practices, and trends in revenue cycle management for hospitals and physician groups.
Don’t Be Tricked by Patient Access Management Vaporware
The foundation of the revenue cycle management process is patient access. Having a solution in place on the front-end can substantially minimize denials and rework on the back-end of the RCM process.
In addition to confirming demographics, insurance coverage and medical necessity, communicating the patient’s out-of-pocket responsibility before or at the time of service significantly increases the likelihood of receiving full patient payment.This shouldn’t be surprising. How many services do you receive that you have no idea what you are going to be charged? The healthcare industry has always seemed to operate amongst their own set of rules. But two major disruptors in the healthcare industry are going to start requiring more cost transparency and more of a partnership between the patient and physician:
1. The transition to value-based care.
2. Consumerism and the continued growth of high-deductible health plans.
As patients are becoming responsible for more and more of their healthcare costs – 30% of uninsured patients or patients who have out-of-pocket costs after insurance generate more than 80% of the hospitals’ self-pay revenue – we are seeing a decline in provider reimbursements for several reasons. The obvious reason is they simply cannot afford to pay their bill, which we will address later. Another less obvious reason is that they simply don’t understand why they are receiving a bill for services when they have insurance. Picture this:
Krystin goes into the hospital for a routine, scheduled colonoscopy. She pays her copay at the time of service and knows she has to pay $1,000 of her remaining deductible, which she also pays at the time of service. However, she is also responsible for coinsurance of 20% after her deductible is met, which is a new component of her health insurance plan that she doesn’t understand. The hospital doesn’t explain or inform her about her coinsurance amount. After the procedure, the provider bills the payer, and receives the explanation of benefits (EOB) stating that Krystin is responsible for $200, the coinsurance amount. The payer then sends Krystin a bill for the coinsurance, approximately 60 days after the service. Krystin receives the bill, but throws it away because it doesn’t clearly explain her balance and she knows she has health insurance, so it must be a mistake. She receives another bill, now 90 days after the service, and again, throws it away thinking it’s a mistake. When she receives a bill from a collection agency, she is confused and now very angry. She calls the provider and is informed about her coinsurance. She is furious that the hospital didn’t inform her about this amount before her service and vows to find a new provider for future services.
Dissatisfied patients also affect your front office staff who have to deal with the angry patients. This often leads to higher turnover rates, as staff will look for a better work environment. That is why patient engagement should be a critical area of focus for your practice. The goals of successful patient engagement should focus on reducing or eliminating:
• Phone calls from angry or confused patients
• Patient statements because they can pay their bill online
• Collections because they have paid their bill or set up a payment plan
• Bad debt for your practice
Of course, that is the ideal state. Most providers have a lot of work to do to get there. But, it is possible. Providing an accurate out-of-pocket estimation is one of the pillars. This is also one of the main functions of patient access software that is commonly vaporware (i.e., software that has been advertised but is not yet available to buy, either because it is only a concept or because it is still being written or designed.) Vendors that are beholden to stockholders, scheduled releases, or big product launches at user group conferences can fall victim to overpromising and under delivering.
Going back to Krystin’s scenario, coinsurance is a piece of the puzzle that is often not included in an out-of-pocket estimation tool. That’s because the tool has to be diligent about maintaining the numerous payer fee schedules, which are continuously changing. Providing an accurate out-of-pocket estimate relies on a solid foundation of eligibility confirmation. A strong eligibility tool will be able to provide – in real time – a patient’s insurance coverage, including copays, coinsurance and deductible information.
Another important component of a patient access tool is determining the likelihood of the patient paying their bill. Checking credit scores and payment history can give you a sense for whether the patient will pay their bill. If it looks like they can’t or won’t, you have options to maximize your reimbursement before you provide the service – by asking for a partial payment or setting up a payment plan, for example.
Through our work with clients and discussions with potential clients, we’ve encountered a lot of skepticism around patient access – particularly the out-of-pocket estimation component. And, that’s where Quadax is different. We are in direct discussions with our clients every day, and our product development is driven by our clients’ needs.
When you’re looking at patient access solutions, don’t be tricked by vaporware. The right solution will be a real treat in maximizing your cash flow.
Ken Magness is a focused healthcare professional with more than a decade of experience in helping clients understand the true value of automation in the revenue cycle management process. As the Strategic Initiatives Leader at Quadax, Ken and his team are passionate about connecting with healthcare providers to help them create and leverage the appropriate technology solutions to optimize the revenue cycle process and improve the experience of their patients and staff.
Hot Topics in RCM: Automation, Patient Experience and Analytics
We recently attended the American Association of Healthcare Administrative Management (AAHAM) Annual Conference in Las Vegas and brought home a wealth of insight… Continue reading “Hot Topics in RCM: Automation, Patient Experience and Analytics”
The Journey to AI Begins with Intelligent Automation
What comes to mind when you hear “Artificial Intelligence” (AI)? From product pitches to the nightly news, the term AI is showing up everywhere. But just what are we talking about when we talk about AI? Driverless cars and robotically-assisted surgery? Postal-sorting machines and facial recognition at Passport Control? Siri and Alexa? Smart forms in EHRs and product recommendations on Amazon? Since this field of research gained popularity in the 1950s, computers’ capabilities have advanced exponentially. As our understanding of human intelligence has also improved, so too has our concept of what programs designed to replace human intelligence should be capable of doing.
Early initiatives to produce AI protocols consisted of distilling human knowledge into programming logic—lines of code to account for every variation of a particular scenario. Chess games could be won by a computer programmed with millions of potential moves, able to go through its library in mere seconds and calculate possible moves and outcomes based on known values. Algorithms were to be credited with success more so than what we today call machine learning. However, in the years between IBM Deep Blue’s defeat of chess master Kasparov in 1997 and Watson’s 2011 Jeopardy win, ground-breaking advances included natural language processing, improved information retrieval, automated reasoning and evolved machine learning capabilities.
Computers are not yet able to replicate human abstract thinking, high-level reasoning, or very complex problem-solving to fulfill the aspiration of “human-imitative AI.” However, advances in machine learning are happening rapidly. According to venture capital firm BGV, “Healthcare creates self-running growth by leveraging technologies that enable machines to sense, comprehend, act, and learn to perform administrative and clinical healthcare functions to augment human activity” and “The market is forecasted to be worth $6.6B by 2021, with a 40% compound annual growth rate.”[i]
Anticipated clinical applications of AI include reading and interpreting diagnostic imaging, producing medical diagnoses, predicting the most effective (and least risky) prescription drugs, and facilitating more productive patient engagement. The journal Nature suggests AI can already diagnose skin cancer more accurately than a board-certified dermatologist.
The non-clinical applications of AI in healthcare are equally promising. AI is expected to transform the data-rich revenue cycle environment into a streamlined, proactive (rather than reactive), healthy financial enterprise characterized by speed and accuracy. The power of sophisticated algorithms to convert data analysis to insights and then to action will eliminate human error, preempt obstacles to reimbursement, and feed strategic discussions.
At this point in time, though, many of the hopes for AI still outstrip its reality.
While work continues to develop capabilities and perfect responses, other issues persist. The AMA Journal of Ethics warns “ethical challenges must be identified and mitigated since AI technology has tremendous capability to threaten patient preference, safety, and privacy.”[ii] Some have raised concerns pertaining to the values programmed into the decision-making algorithms—whether biases inherent to the humans developing the technology are lurking in the AI. How legal liability will be handled in cases of unintended consequences or errors in judgment. And more basically, whether or not an AI system can be trusted.
Undoubtedly, technology will advance to an integrative intelligence model combining different competencies (machine learning, natural language processing, vision, predictive modeling, and robotics) to produce human-imitative AI, and the accompanying ethical and legal dilemmas will be explored, debated, and resolved.
In the meantime, revenue cycle professionals will realize significant benefits from technologies upstream of human-imitative AI. The starting place for the progression of artificial intelligence development, as we have seen, was a rules-based, if/then schema we may now think of as Intelligent Automation (IA). IA is now offering cost savings and operational advances to healthcare organizations.
Intelligent automation features rules-based routines to enable an application to handle repetitive tasks, particularly those with high-volume. Any time there is a clear relationship between the circumstances necessitating intervention and the prescribed solution, it can be—and should be—automated. In the revenue cycle, such tasks are abundant. Prime candidates for automation include eligibility processing, assigning workflow statuses, correction of known errors, cross-walking new provider credentials, claim status checking, remittance splitting, payment posting, and other revenue cycle tasks which are not complicated, but typically require mind-numbingly repetitive manual intervention.
IA delivers on the promises often attributed to AI for streamlined work, greater productivity, and lower costs. For example:
- Streamline your claims management by relying on IA for data conversions, workflow management, auto-correction of known issues, and segregating those claims requiring extra attention prior to submission.
- In your denials management and your collections efforts, use IA to move toward an exception-based work environment for greater productivity and a reduction in the volume of work you must outsource.
- Automating certain revenue cycle tasks gives you extra bang for the buck – consider revenue leakage uncovered by the intelligent analytics of a contract management system. Using human capital, you can’t necessarily afford to pursue large quantities of low-dollar shortages. With automated efforts, you can. You win by not only repurposing staff and pursuing the high-dollar shortages staff already worked on, but also by recovering shortages previously written off.
Another tremendous advantage of the implementation of IA is the freedom to move human capital away from menial tasks into more meaningful work. The workforce is thereby enhanced, improving both staff retention and expanding reach to improve operations.
When Adena Health System implemented RemitMax to convert paper-based payment documents to machine-postable ANSI 835s, jobs within the business office, particularly for cash posters, were radically revised. Angela Lowery said, “It’s changed our mindset from ‘gotta key, gotta key, gotta key’ to an analytical approach of identifying payment problems and working toward solving them. You’re thinking, you’re reviewing, you’re analyzing, you’re contacting other teams and working with them. It’s truly been transformational.” (To learn more about the benefits Adena Health enjoys with RemitMax, read the case study.)
Begin the Journey
The science and technology of artificial intelligence will inexorably become more complex with greater precision, particularly for clinical applications. As AI continues to mature, don’t miss the opportunities afforded by IA.
Quadax solutions reduce complexity in the revenue cycle with intelligent automation in the areas of patient access, claims management, reimbursement management, denials and appeals management, and business intelligence. Using Quadax tools, our clients enjoy more control, better data, and better cash flow. Let’s talk about the difference Quadax IA can make in your revenue cycle!
[i] https://benhamouglobalventures.com/2018/08/02/digital-transformation-of-healthcare-state-of-the-union/
[ii] AMA J Ethics. 2019;21(2):E121-124.
The Power of Physicians
How will the healthcare system benefit from physicians unleashing their true power?
From hospital acquisitions to primary care shortages to the impact of telemedicine and value-based care, the role of the physician is changing. They now have an opportunity to take center stage in the new world of healthcare.
Key Takeaways from this presentation:
- How policy changes impact independent physicians
- Why physicians should embrace leadership roles
- How the primary care physician role needs to be enhanced
- The importance of data analytics to understanding the patient base
Presenter: Thomas Campanella, Baldwin Wallace University
Mr. Campanella is the Director of the Health Care MBA program and a professor of health economics for Baldwin Wallace University in Cleveland, Ohio. He also writes a healthcare blog on LinkedIn, follow him here.
How does your zip code impact your health status?
Cleveland, home to Quadax headquarters, is also home to some of the finest medical facilities in the world. (Many of them, we’re proud to say, are Quadax clients.) At the same time, out of 88 counties in Ohio, Cuyahoga County (the greater Cleveland area) ranks 62nd for health outcomes[i]. Overall life expectancy is 1.6 years below the national average. Infant mortality is well above the national rate, with significant racial disparity. In terms of health factors contributing to outcomes, Cuyahoga County ranks 86th in Ohio for Physical Environment, and 81st for Social & Economic Factors, which include children in poverty, income inequality, unemployment, and violent crime.
In response to this dichotomy, Dr. Akram Boutros, M.D., FACHE, President and CEO of The MetroHealth System said, “It’s time to stop applauding medical care that’s administered after the fact, no matter how good it is, and start providing health care before people get sick.”[ii]
The MetroHealth System is doing just that, as announced in their recently-issued 2018 Annual Report, with the new Institute for Health, Opportunity, Partnership and Empowerment (H.O.P.E.)—just one of the programs they’ve created to identify and act on social determinants of health.
The Centers for Disease Control defines Social Determinants of Health (SDoH) as the conditions in the places where people live, learn, work, and play affecting a wide range of health risks and outcomes.[iii] “Right now in the United States of America in the year 2019, your zip code is more predictive of your health outcomes than your genetic code,” says Kate Walsh, President and CEO of the Boston Medical Center Health System. Commonly cited research reveals the contribution of clinical care to an individual’s health to be only about 10%, while socio-economic conditions, health behaviors, and physical environment combine to contribute 80% to a person’s health status.
Figure 1. Source: Minnesota Department of Health
Lists of SDoH vary in number of categories, based on the arrangement of contributing factors, depending on the source. The CDC identifies five key areas; this table (below) from the Kaiser Family Foundation arranges the factors into six categories:
Figure 2. Source: Kaiser Family Foundation
The relationship between social conditions and health has been recognized for many years. Now, as our health care system shifts further toward value-based care, ever greater attention is being given to these socio-economic factors which will either support or undermine medical intervention.
AARP has found social isolation among older adults is associated with an additional $6.7 billion in Medicare spending annually. In people of all ages, factors such as social support, food security, economic stability, and physical safety will dictate their adherence to plans of care, making appointments, and avoiding hospital readmissions.
In a reimbursement environment focused on outcomes, providers will see greater success when patients’ health is established and maintained over the long term, enabling them to consume fewer acute care resources.
It’s a Community Thing
Dr. Boutros has stated, “Poor health doesn’t just affect the sick; it impacts entire communities.”He also observed, “The chronic stress of poverty has been demonstrated to hinder the development of executive function and to create dysregulation of emotion and attention. These lifelong effects are some of the underlying reasons why children living in poverty may not excel in school, choose risky behavior and have more suicide attempts.”
To that end, MetroHealth has developed programs to address Physical Environment, Health Behavior, and Socio-economic Factors in order to improve physical and mental health and reduce health care costs. The Institute for H.O.P.E will become a hub to provide access to resources and programs for education, employment, food, transportation, and housing. A grocery store, food pantry, classrooms, legal aid services, and financial literacy training are just some of the features planned. MetroHealth has also announced plans for new apartments, programs for employee assistance, and telemedicine service for college students in four states. These programs add to a long list of initiatives designed to transform the community, including the Open Table model.
A little less than two hours to the west of The MetroHealth System, ProMedica is likewise committed to caring for their community: the greater Toledo area, stretching into southeastern Michigan. In 2015, partnering with the AARP Foundation, ProMedica announced the formation of The Root Cause Coalition, a 501(c)(3) nonprofit organization to address hunger and other social determinants of health. In the same year, it opened its first food pharmacy, distributing food to patients with a physician referral. Since then, two additional Food Clinics have begun operation, and overall the Food Clinics have served more than 6,600 distinct households with “food as medicine.”
Recognizing many in ProMedica’s community live in food deserts, ProMedica has also invested in Market on the Green and a Mobile Market to bring fresh, local produce and fresh meat, dairy, and more at affordable prices to families and individuals who otherwise would never see fresh, healthful food in their neighborhoods.
According to Randy Oostra, President and CEO of ProMedica, “The healthcare industry must not only deliver clinical excellence and efficiency, we must hone in on how we can act as catalysts, innovators and leaders to improve the health of our entire communities.” Oostra has also observed that there is a business case for addressing social determinants of health in terms of lowering health care costs, reducing absenteeism, and increasing productivity.
Getting There from Here
In 2017, the Deloitte Center for Health Solutions conducted a survey of about 300 hospitals and health systems about health-related social needs investments. According to their findings, “80 percent of hospital respondents reported that leadership is committed to establishing and developing processes to systematically address social needs as part of clinical care.” However, current activity is often fragmented and ad hoc. There are gaps in screening, and finding sustainable funding is a challenge. Those hospitals making the greatest progress toward value-based care models, such as accountable care organizations (ACOs), are reporting the highest level of activity in the area of addressing social determinants of health.
Research into the association between social services coordination by health systems and a reduction in health care expenditures has to date been limited, but preliminary studies do show a positive correlation. A study conducted by WellCare Health Plans and the University of South Florida College of Public Health found a 10% reduction in health care costs for people who were successfully connected to social services for needs such as housing services and utility assistance.
Effective analysis of the return on investment for addressing social determinants of health requires hospitals employ data analytics to track meaningful measures—and to be patient as results are more likely to be seen over the long-term. Collecting data, selecting meaningful metrics, and understanding which components are providing the greatest ROI will depend on collaboration between clinical areas, social service partners, and revenue cycle representation.
While the data and analysis may take years to capture and understand, the data presently available on the connection between SDoH and health outcomes is clear and compelling.
As Dr. Boutros has pointed out, we have known for twenty years that increased Adverse Childhood Experiences lead to increased likelihood of diabetes, obesity, depression, sexually-transmitted disease, or suicide attempts. We also know, just as low-income Americans suffer higher rates of heart disease, diabetes, stroke, and other chronic conditions, poor health statuses also contribute to lower income, creating a cycle that’s hard to break.
Moving interventions upstream presents numerous challenges, but as characterized by Dr. Boutros, it’s a moral imperative.
Quadax applauds the efforts of The MetroHealth System and ProMedica in going beyond symptoms to tackle root causes and enhance the overall health of these Ohio communities.
In future articles, we’ll examine other SDoH initiatives as well as practical steps for moving forward with such efforts.
[i] https://www.countyhealthrankings.org/app/ohio/2019/rankings/cuyahoga/county/outcomes/overall/snapshot
[ii] Dr. Akram Boutros, “What Hospitals are Getting Wrong and How We Can Fix It,” delivered at The City Club of Cleveland, June 7, 2019. https://www.cityclub.org/forums/2019/06/07/what-hospitals-are-getting-wrong-and-how-we-can-fix-it Transcript here.
Realign Claim Follow-Up Value For Today’s Revenue Cycle
Take a deeper look at effective claim follow-up and how it can inform upstream denial avoidance measures.
How can you realign your follow-up process to deliver the value you really need for today’s revenue cycle?
Effective claim follow-up enables a healthcare facility to proactively identify and begin working claim denials or requests for additional documentation. The most commonly used methods of claim status checking are fully manual, partially electronic, and ANSI.
In this guide we will cover each of these methods in terms of effectiveness by asking the following questions:
√ Information quality: is it actionable?
√ Response speed: is it timely?
√ Effort required: is it cost-effective?
How to Improve Patient Satisfaction and Your Bottom Line
Patient satisfaction is an important goal for providers for reasons going way beyond a desire to be kind humans. It’s the first part of the Institute for Healthcare Improvement Triple Aim.[i] Better patient satisfaction has been associated with better medical outcomes and with reduced readmissions.[ii] Patient satisfaction scores influence reimbursement, both for the Inpatient Prospective Payment System (IPPS) and value-based care. And, in an era of competition for patients from non-traditional healthcare outlets, ensuring patient satisfaction is an important way to protect patient relationships and future revenue opportunities.
Ways to achieve better patient interaction are not closely-held secrets. Lists of helpful tips may be found in abundance in collections of 5 or 10 or even 30 top ways to improve patient satisfaction. Boiled down to the most common theme, though, it’s all about Communication, Communication, Communication.
The characteristics of good communication– listening patiently and respectfully, making eye contact, answering questions fully, expressing empathy –belong in both the clinical and in the financial environment.
Communicating Patient Financial Responsibility
The Healthcare Financial Management Association (HFMA) published a comprehensive guide to patient financial communications in 2016 which remains a valuable resource on the topic. The guide was developed in partnership with experts including representatives of patients, hospitals, and physicians, advised by national policymakers including Sen. Tom Daschle, Sen. Bill Frist, former Secretary of Health and Human Services Donna Shalala, and others. Its goal is to bring “consistency, clarity, and transparency” to patient financial communications with best practices for Emergency Department (ED), time of service (outside the ED), and advance of service settings.
One best practice identified for all settings is, “Providers should have technology that gives financial representatives up-to-date information about patient balances and financial obligations.”
Patients today are frequently, and understandably, anxious about the debt they may incur for diagnosis and treatment. Twenty-five percent of Americans, according to Gallup, name cost as the most urgent health problem facing the U.S. Forty-five percent of Americans fear a major health event will leave them bankrupt.
Clear, credible, compassionate communication, then, about a patient’s financial obligation is essential to caring for patients in a way that will foster satisfaction and result in better outcomes.
Fortunately, the technology to give patient access or financial representatives up-to-date estimates of a patient’s out-of-pocket responsibility is available and easy to use.
In the Quadax Patient Access Management suite, the Out-of-Pocket Estimation tool is a contracts-based estimation engine able to produce an individual professional or technical estimate or a combined estimate. The engine analyzes the provider’s negotiated contractual stipulations, chargemaster, historical procedural information, and patient-specific, year-to-date benefit data to arrive at the best estimate of a patient’s financial responsibility possible prior to the current procedure. Auto-add technology includes related procedure codes—additional procedures found to generally be done in conjunction with the primary procedure—for a more realistic estimate to eliminate surprises down the line.
Patient Access representatives using the Quadax Out-of-Pocket Estimation tool are guided through the process of generating the estimate and talking with the patient about the document. Through this open communication, a patient is better equipped to make care decisions and financial plans, and is more likely to express satisfaction about the financial communication experience with their healthcare provider.
Are you ready to learn more about the role an easy-to-use Out-of-Pocket Estimation tool can play in your mission to provide care to your patient population? Click here to request a no-obligation consultation.
Fostering high patient satisfaction is one way of thriving in an environment of increased competition for patient-consumers. A recent Definitive Healthcare survey of important trends identified consumerism as the second most important topic causing apprehension for healthcare providers. If the rise of consumerism in healthcare today has you concerned about the implications for your practice and for your patients, request our latest White Paper, Healthcare Consumerism & Your Revenue Cycle: Flip the narrative and build loyalty through patient-centric tools and processes. Request your complimentary copy here.
[i] http://www.ihi.org/engage/initiatives/tripleaim/Pages/default.aspx
[ii] Jacob Imber, MD, “Lower rates of patient satisfaction may predict readmission,” The Hospitalist, May 23, 2019, https://www.the-hospitalist.org/hospitalist/article/201061/mixed-topics
Healthcare Consumerism & Your Revenue Cycle
Take a deeper dive into understanding consumer trends and how they affect the management of your whole revenue cycle.
Patient Responsibility Strategies in 2019
In this webinar, Lyman Sornberger discusses how today’s patient responsibility trends necessitate changes to traditional revenue cycle models.
Learn what your peers are doing with operations, technology, and relationships and explore our new era, beyond revenue cycle management (RCM) into revenue cycle leadership (RCL).
Presenter: Lyman Sornberger, CEO at Lyman Healthcare Solutions, LLC.
Mr. Sornberger is a national speaker and consultant, bringing more than thirty years’ executive experience to this important discussion. He will share the NEW end to end insurance and patient collection concepts to improve performance.