Upfront financial clearance part of strategy
Health care organizations aware of their need for systemic change but short on the capital required increasingly are taking a two-pronged approach: Make some quick revenue-producing hits first, and then implement the longer-term solutions. That’s just one of the strategies in place at Parkland Health and Hospital System in Dallas, a publicly funded teaching facility with 800-plus beds and a large unfunded patient population, says Laura Fawcett, a Detroit-based manager for the consulting firm Cap Gemini Ernst & Young.
"We’re starting by trying to make process changes, which are then followed by system enablers’ to get the next level of value," Fawcett adds.
At Parkland, she explains, the focus is on two things: increasing collections at the time of service, which can provide a financial quick hit, and reducing payer denials, a longer-term value. In other cases, Fawcett notes, the patient access strategy might be to target unbilled reduction, or accounts in the discharged-not-final-billed category. Some organizations put a hold on accounts pending insurance verification or other information, thus delaying billing and slowing down the revenue cycle, she says. "There can be a large backlog."
"Others don’t hold anything," she points out. "That’s not necessarily good, if it goes to the wrong payer or the wrong place and you have to resubmit, or if you should have had authorization."
"With [upfront] collection," Fawcett says, "you start seeing cash immediately, and it’s a recurring benefit." Although Parkland already does some time-of-service collection, albeit with a lot of variation by service, "you’d be surprised at how many organizations we go into that don’t collect any money.
"Part of the challenge is a culture in which the perception is that care is free," Fawcett says. "Even patients who have a copay or other financial responsibility are not asked to pay because of that culture." For that reason, she adds, training will center on managing customer expectation.
Through advertisements in the local newspaper, press releases, and communications with staff in medical offices, Fawcett notes, "we’re trying to create the awareness in the community that this [collection effort] is going to occur." The ads, she says, will include the answers to questions commonly asked about the process, such as, "What should I expect in terms of [the amount of] money to bring?" or "If I have an emergent condition, can I still be treated [without payment]?"
The answer to the last question, of course, is yes, Fawcett adds, noting that information also will be provided, for example, on the cost of a typical office visit, as well as why the health system is taking such an action.
Starting at scheduling
At Parkland, Fawcett explains, a big piece of the initiative is to put the collection process in motion at the time of scheduling — well before the patient is standing in front of a registrar being asked to pay for a service that already has been given. To channel patients as needed, key data will be gathered during scheduling, including insurance verification and authorization information, she says. "If a patient needs a referral, for example, the person will not be scheduled at that point, but will be directed to a case manager, who will try to ensure that the referral is in place. Then the patient will be scheduled."
"We’re trying to make sure we focus on getting the patient financially cleared as soon as possible," Fawcett adds, by addressing two issues: Does the patient have insurance and, if so, how does the hospital communicate with them early about copays or deductibles?
For patients without insurance, she says, the focus will be on matching them with financial counselors early in the process to pursue coverage through Medicaid or another program. "Up to now," Fawcett adds, "there has been no screening up front to make sure the patient is channeled appropriately. The patient is here and is assigned to a counselor, but if the person doesn’t qualify or should be in another county, it’s already too late. The opportunity lies in getting funneled prior to service."
At Parkland, where registration is decentralized at present — with a long-term goal of centralizing the process — gathering of the mandatory, upfront data will be done in some areas by clinicians and in others by clerical employees, she says. "In the short term, we’re keeping everyone where they are, and identifying the tools and processes to collect that information," Fawcett adds. "[Employees will obtain] the name, address, medical record number, insurance information — including authorization and referral — and will make sure they have a telephone number for the patient."
In the past, she says, information obtained up front likely would have included the person’s name, the date and the reason for the visit, but none of the financial information.
As training for the new process got under way in early July, Fawcett notes, the concern among managers was the time that would be required to gather the data and "how to fit that into the work [schedule]."
Another piece of the puzzle — as well as a catch phrase that is gaining momentum among proactive access departments — is a "deny/delay" policy, which calls for financial clearance up front, she says. "If you’re not able to get the patient the appropriate authorization or referral, and the case is non-emergent, you wait and reschedule."
Ideally, this step takes place while the patient is on the phone to schedule the appointment, Fawcett says, but it could happen in person. If it’s the latter scenario, she explains, the registrar would say something such as, "You need XYZ to be financially cleared for this service," and would offer the patient a couple of choices: "We can reschedule you at a time when you have that [clearance] or provide the service and you sign a waiver indicating you might be financially responsible."
The key to long-term success in a project such as Parkland’s is "being committed to sustaining the change," she points out. "What I’ve seen with some organizations is that they start the process, but after a few months, the enthusiasm dies down. What we do to try to maintain it is to put measurements in place. What are we collecting per area? How does it measure up to our goals?"
Everyone knows the measures are there and expects reports on how it’s going, she adds. "It’s just staying committed to that. Continue training and continue to reinforce with the people on the front lines."
[Editor’s note: Look for a progress report on the process change under way at Parkland Health and Hospital System in a future issue of Hospital Access Management.]
Health care organizations aware of their need for systemic change but short on the capital required increasingly are taking a two-pronged approach: Make some quick revenue-producing hits first, and then implement the longer-term solutions. Thats just one of the strategies in place at Parkland Health and Hospital System in Dallas.
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