2022 healthcare trends driving change in patient financial engagement

Sponsored by CarePayment

Disruptive changes brought on by rising medical costs and increased patient cost sharing require an evolution in traditional patient billing and collection practices. Rapidly changing state and federal regulations, COVID-19, consumer behaviors and expectations, disrupters, technology and operational challenges impact healthcare in parallel.

Industry shifts force providers to update their strategies and implement more flexible, patient-centered collection approaches meeting patient needs while facing internal operational challenges and maintaining compliance with new regulations.

Shawn Stack: How have COVID-19, new technology and operational challenges shifted the patient financing landscape?

Michael Alwell: When COVID started, our organization realized that we would need to devise a remote work strategy very quickly. We were able to provide some IT security measures, but at the time, we did not have equipment for staff to use at home so they had to use their personal computers and telephones. We saw that some employees’ internet connections were slower than others, especially when the employee had others working or schooling from home at the same time, so there were some challenges related to accessing accounts and applications. We still had paper coming into the hospital, so we had to ensure that it was all scanned and sent to the appropriate people as timely as possible. On the clinical side, we had no telemedicine infrastructure, but were able to stand up three different platforms within six weeks. We were also ultimately able to apply for and receive funding from the FCC telemedicine grant program.

Hilda Dalfonso: Our population has a high density of elderly, with many of them preferring to come into the hospital to make that payment. Pandemic visitation restrictions challenged that. We moved our back-office workforce to work from home. The challenge of making sure technology, tools and resources were in place as patients called in defines what the future might look like long term. In person connections in the hospital setting with uninsured patients presumably qualifying for some government-based plan shifted. Trying to vet patients with no restrictions and isolation precautions versus those that did was a management challenge. We leveraged techniques like iPad to support that face-to-face, putting a burden on a clinical team member to help facilitate.

Girish Dighe: COVID-19 staffing shortages were a major impact across the revenue cycle and redeployment efforts. We think about how we have to shift our business including patient-facing roles, pre- and post-service collections and even staffing shortages seen by the payers who had to adapt. We continue to deal with the connection between payers and providers on accounts receivable management and prior authorization management affecting patient financing. New CMS and OSHA vaccine mandates/regulations may mean we may see a change in workforce management. I’m worried about how we do not compromise the patient financial experience when dealing with revenue cycle operational challenges and administrative burdens.

Laurie Hurwitz: With face-to-face restrictions with patients — [and] staff out because they were sick, taking care of sick family members or no longer had childcare, and they couldn’t be in a building to interact with the patient — [meant we needed to] find as many self-serve options for patients as possible. Many patients with COVID, who had never been in the health system, have been shocked by what they owe. They don’t understand their benefits or deductibles. More patients need financing. We need structural systems in place where patients can take care of that themselves. I don’t have enough people to answer the phones. It shouldn’t be any harder to get financing than it is for buying a car.

Sharon Kelley: We piloted ‘advanced care at home’ where the entire in-patient stay is done in the home. We received a Medicare waiver for that. We’re working with our managed care payers [who are] less willing to help us because of the billing implications. You’re bundling an episode of service. It’s very important for the future that hospital care to a certain level will be done completely within the home setting. We moved everybody to an electronic statement over a three-month period. They had to opt out to continue to have paper. That saved us about a million dollars a year in statement costs and allowed us to meet patients where they were. We looked at Epic system enhancements with a one through five on a propensity to pay. We’ve rolled out Apple Pay. We’ve suggested payment plans on the statement based upon Epic logic. We’re working with a vendor to use artificial intelligence [to monitor] our call center calls, providing an empathy score, and why they’re calling, [and also] to determine over time [the patient’s] key point and why people call a second time.

Samantha Evans: We put a lot of effort into a back-end artificial intelligence solution. Prior to [COVID-19], you could only pay two ways: through a paper statement or through MyChart. Now, the solution uses AI to determine a patient’s preference on their billing method. Some patients like to pay through text messages, while others like to engage through email or paper statements. We have a portal where patients can set up their own payment plans within our established guidelines and can add new invoices to the plan as they become available, all without having to talk to a customer service rep. If they can’t manage a payment plan within the guidelines, we’ve added financial assistance language and other options as well. We always knew we were going to go here — COVID just sped it up for us.

Stack: Have consumers embraced these nuances with telemedicine and electronic tools to help make financial payments?

Hurwitz: At OSF, 75% of patient payments are made self-directed online.

Jim Heffernan: Our patients do their own scheduling for routine and follow-up visits. People adopted telemedicine. We’ve found patients don’t miss a visit they themselves have scheduled.

Alwell: We’re opening up an inventory facility that’s going to be patient-centric and rolling out self-scheduling.

Evans: AnMed Health is also looking at solutions to help patient’s self-schedule certain services and office visits. You have some physicians wary of opening up their schedule, and we have access issues as we continue to grow our patient population. We’ve started small with self-scheduling on things that don’t require authorizations or are only once a year, and we’ll build from there.

Dennis Shirley: Patients serving as their own registrars allows them to schedule their own appointments or pre-registration online. We present questions to answer ahead of time and put the right tools in to ensure accuracy and validate items. It reduces the burden on our front desk.

Dighe: We’re thinking about consumerism and have an initiative called the ‘customer for life.’ We’re looking at ways to think about an omnichannel experience to best serve our patients by the way they want to be connected to us. Let’s make it easy for patients to navigate financial obligations and/or support financial assistance opportunities. With telehealth services, we still have growth opportunities to partner with our clinical teams to make patient access easier. Lastly, the use of advanced practitioner providers can complement our physicians in better overall provider utilization and throughput to meet the consumer’s healthcare needs.

Brian Brown: Working with large provider organizations nationwide, we saw a rapid shift in operational models, particularly as it relates to the patient financial experience due to COVID. COVID, which forced us to be remote, also forced us to look at new technologies and automation to maintain touchpoints with the patient. And, after two years of managing their own registration and scheduling, clinical care via telemedicine, billing inquiries via portals and apps, patients feel more in charge of their care. Providers are looking for partners who can maintain this for patients and make the financial experience very satisfying. Many times, the revenue cycle is where a patient first interacts with a provider, and it is their last touchpoint. We all have to have margin top of mind, which demands we address all patients with all balance sizes and any financial status where they are in their journey. There has to be an omnichannel approach of having multiple tools to support the patient population.

Stack: What are the challenges in balancing the No Surprises Act revisions with clinical workflows?

Dalfonso: As an industry we have committed to a clean claim submission. We’ve all had different experiences around that front end — cost assessment and patient experience — which is what the act addresses. We doubled down on a previously delayed initiative to set up payment plans in advance of scheduled procedures. We’re discussing cost in advance with the patient, making sure they’re aware of their risks or financial exposure and are comfortable with the established payment plan. We extended the payment plan time length. However, having a finance-focused discussion at some point in that care can be very off-putting to a patient and their loved ones. Not to mention that we may not have insights on what every caregiver along the episode will bill them. I hope we don’t wait until there is legislative force. We need to continue to prioritize this work for the patient’s sake.

Stack: Are any of you doing patient education or outreach on what No Surprises means to them?

Mary Beth Remorenko: We’re starting with communications explaining the legislation and surprise billing, particularly with patients whose insurance coverage is out of network. We’re sending them a proactive communication explaining their options and providing them with an estimate. This shifts to more of a retail-type of patient experience. If a cancer patient needs surgery that’s not an emergency and the payer is out of network, we’re now required to give an out-of-pocket cost estimate. We’re all nervous as providers to make sure this doesn’t result in patients choosing to delay their care, not get the care they need or go elsewhere.

Evans: We implemented a patient estimator tool (PET) in 2019. We’re at about 50% accuracy almost three years in. This is tough. When the physician changes what they do once the patient gets back there, how can you ever be within $400 of every estimate?  One pharmacy or lab charge can make that difference. If I’m a self-pay patient, how do you ever figure it out perfectly on the front end and marry that with what’s really going to happen on the back end? Our point-of-service initiative was a huge culture change here at AnMed to ask for money before a service, and we’ve paired that with the (PET). We’re giving a best estimate with our templates and historical data available, but these new guidelines have almost made this required accuracy impossible.

Alwell: Our estimator tool is as good as it can be for that particular moment in time when the estimate is prepared. We have had cases where a patient meets their deductible between the time the estimate is generated and the time of service. We’ve had patients avoiding care believing they were going to have out-of-pocket expenses, only to find that their colonoscopy or mammogram is covered as a screening procedure with no out-of-pocket expense. Our pre-visit services have had positive impacts on patients.

Heffernan: Many times, the retail outpatient pharmacy formulary is very different than the drug patients were started on in the hospital. That isn’t a surprise billing issue. Maybe insurance companies should be collecting the deductible and co-pay. We do due diligence and think the patient’s covered. Many times, the employer contract with the payer excludes certain things you assumed would automatically be in the contract.

Kelley: The pharmacy prior authorization for the retail pharmacy is the biggest dissatisfier with our physicians. The physician writes a prescription, and the plan doesn’t cover it. The emergence of pharmacy is becoming a huge issue: high-cost drugs, brown bagging, white bagging. The medical policies health plans are putting on the providers is a huge issue with our prior authorization groups. They didn’t have clinical input. One area of focus for us is unexpected bills going to our patients, [which] we need to proactively resolve.

Heffernan: The biggest dissatisfiers/burdens on our patient physician surveys has been prior authorizations. There are medical practices with full-time nurses who only do pharmacy authorizations. They can’t keep these nurses; if you’re an experienced nurse, do you really want to spend your day getting prior authorizations? The hospital is looking for authorization for something we’re going to get paid for — the physician is trying to get authorization for services that their patient needs but the physician is not directly providing.

Alwell: Pharmaceutical companies’ direct-to-consumer advertising is exacerbating problems with some higher cost structures. Patients going into the physician’s office saying they want something they saw on TV, [and they] find out there’s a huge co-pay.

Mark Krieger: Payers are in a better position to do the estimating. They have a much larger database than we do spanning different types of plans and patients. They’re able to mine data for a procedure, particularly if it’s pre-authorized. Our efforts should be to bring in pharmaceutical companies and insurers and help legislators understand where the accountability should lie to get the best patient outcome in this ‘No Surprises’ arena.

Brown: The act is creating a financial liability for health systems. They’re potentially not able to charge for procedures they’re providing and deterring patients from seeking the care they need. We see more payers ask patients for co-pays and bill them directly. That speaks to why the tools to address the patient [are] so important for the health system; being in charge of that patient experience — not just the care experience, but also the financial experience.

Dalfonso: There’s growing tension — midstream care having to reach out to the provider and say something’s different from the pre-authorization creates a distraction from what that provider is here to do and adds to their prospective administrative burden. There has to be collaboration across all providers.

Stack: What are you looking for in partners to achieve these goals?

Remorenko: Being more proactive. Sometimes it feels like pulling teeth to
get what we have to have versus thinking about what do we optimally need two
years from now.

Kelley: The recognition we’re going to have a much smaller revenue cycle where automation and higher-level competencies are going to be required. How vendors fit into that strategy of the new revenue cycle, where we see ourselves in the next three to five years, is key.

Alwell: Any patient-facing vendor I deal with has to live our mission and values. We’re a faith-based organization and large safety-net facility. After ensuring that the vendor shares our values, will we start looking at their offerings, ROI and systems integration.

Dighe: We are promoting across the enterprise that revenue cycle management isn’t just a department, it’s a concept. It’s critical to bring multidisciplinary teams together — such as IT, transformation/strategy, clinical teams, providers and operations — to problem-solve together on revenue cycle management. 

Dalfonso: We need to make sure we’re advancing this work in parallel with value-based care and reimbursement and new delivery of care models.

Evans: It’s tough sometimes if you have four to five vendors in one bucket of work. It’s imperative to have clear expectations and benchmarks on not only what we’re tracking, but how we’re tracking it. Being able to track results individually by vendor is crucial in the management of performance.

Heffernan: I’ve been looking for vendors who know how and want to work between the providers and the payers. 

Certainly, the COVID-19 pandemic brought on disruption to the workforce and patient engagement.

Going forward, the driving factors key to mitigating such challenges focus on flexible payment delivery options — from in person to electronic — respecting patient preferences and creating workforce efficiencies. Patient education and outreach — as well as collaboration among healthcare providers — with respect to the No Surprises Act is critical. Vendors who can provide solutions to challenges in working between providers and payers will provide the greatest value.
 

HFMA Roundtable

PANELISTS

MICHAEL ALWELL
Vice president of revenue cycle at St. Joseph Health in Paterson, N.J.

BRIAN BROWN
Vice president of sales at CarePayment in Nashville, Tenn.

HILDA DALFANSO
Vice president of finance at SCL Health, Broomfield, Colo.

GIRISH DIGHE
Vice president of revenue cycle at OhioHealth in Columbus, Ohio.

SAMANTHA EVANS
Director of patient financial services and patient access at AnMed Health in Anderson, S.C.

JIM HEFFERNAN
Senior vice president at Massachusetts General Physicians Organization in Boston

LAURIE HURWITZ
Senior vice president of revenue cycle at OSF Health in Peoria, Ill.

SHARON KELLEY
CFO, Mayo Clinic Health System in Rochester, Minn.

MARK KRIEGER
CFO at Barnes-Jewish Hospital in St. Louis, Mo.

MARY BETH REMORENKO
Vice president, revenue cycle operations, Mass General Brigham (formerly Partners HealthCare) in Somerville, Mass.

DENNIS SHIRLEY
Vice president, revenue cycle, UnityPoint Health in Des Moines, Iowa.

MODERATOR

SHAWN STACK
Director, perspectives & analysis at HFMA, Washington, D.C

SPONSOR

CarePayment is a patient financing company that accelerates healthcare providers’ transition to the new consumer-driven healthcare market. Powered by advanced technology and analytics, our innovative patient financing solutions improve patient satisfaction and loyalty while delivering superior financial results. By partnering with healthcare providers to make affordable financial options available, CarePayment helps patients get the care they need, when they need it, while protecting the financial health of provider organizations so they can continue to offer valuable care to the community. CarePayment’s patient-friendly financing is compliant with applicable state and federal consumer credit laws, requires no application, and is supported by a friendly US-based customer service staff. Accounts for the program are issued by Republic Bank & Trust Company, Member FDIC. Find more information at carepayment.com.