ScrippsHealth’s 2000 goal: Move patient collections to the point of service
Preauthorized payments will be the norm
Paying a hospital bill will become a lot more like buying a new television if all goes as planned at ScrippsHealth in San Diego. The goal at the six-hospital health system is to move the heart of the collection process to the point of service and reduce by 80% the number of patients who require a collection call by September 2000, says Dan Kehl, director of collections and customer service.
A key part of the plan, Kehl explains, is getting a commitment from patients upfront for their share of the bill. "We’re taking a hard look at treating [payment for health care services] more like a retail installment agreement, getting back into the world of promissory notes and preauthorized payment."
Scripps will move away, he adds, "from the historic model of two or three letters, then phone calls, then, if there’s still a balance, going to collections. If we’re successful on the point-of-service [POS] side, we won’t have to go down the road of, If you don’t pay by X date, we’ll send it to a collection agency.’"
As in retail, when payment is preauthorized to take place once delivery of goods is made, the patient’s credit card would be charged once Scripps has determined from the insurance company exactly what the patient owes, he says. "We’d already be preauthorized to take [for example] $50 per month on the credit card. The goal is not necessarily to collect [upfront] 100% of every patient portion due, but to secure a prearranged payment."
"We know we cannot continue to sustain large amounts of accounts receivable," Kehl adds. "It’s the same old story — the longer you wait to get the money, the less value it has." To achieve its goal, Scripps has put together a multifaceted effort that centers around improved customer service, he says. "The happier patients are, the more likely they are to pay the bill."
With that in mind, he explains, Scripps is moving away from "the historic model of the confusing hospital bill." The health system has heard from its patients — through extensive focus groups and surveys — that they want "access to more information they don’t have and quicker response to inquiries and questions."
The patients let Scripps know, for example, they wanted the access representatives to explain their insurance benefits to them, he notes; they felt that was the health care provider’s job. To respond to that request, Scripps will offer patients more complete information and payment options at POS or, better yet, at the time of scheduling, Kehl says. All six Scripps hospitals now have the same policies and procedures for POS collection, he notes. "Historically, each hospital had a customized way of doing things."
Giving price estimates for procedures, for example, is "part and parcel to the POS program, so that patients don’t get a different price at different facilities," Kehl says. As of the past fiscal year, which ended Sept. 30, 1999, Scripps created and implemented a systemwide chargemaster to ensure that consistency, he adds.
Employees from the central business office and those at the different hospitals worked together to resolve the customer concerns brought up during the patient focus groups, he notes. One of the benefits of that collaboration, Kehl adds, has been better communication between the two groups. (See related story, p. 27.)
Instant eligibility check
Part of the Scripps POS solution will be a system — expected to be in place by the end of February 2000 — that checks insurance eligibility automatically as the patient is being registered, Kehl says. Before patients leave the registration desk or hang up from the scheduling call, they will know whether they’re eligible for the service and how much the copayment or deductible will be, he adds. "Historically, that would take a phone call lasting up to 30 minutes. We don’t have the labor available to do that."
Scripps is a beta site for Delray, FL-based software vendor Eclipsys Corp., which is designing the insurance eligibility system using a product from Envoy Corp. in Nashville, TN, says Kehl. Some systems for checking insurance eligibility fall short because they aren’t comprehensive enough in the third-party payers they handle. Envoy, however, has agreed to pursue aggressively the carriers Scripps needs that the company doesn’t currently cover, he notes.
"The end result is going to be an integrated eligibility system that is part of Eclipsys," Kehl says. "It will automatically go out and do the inquiry and then populate the [registration] screen with the information."
Education is the key
To make the POS collections model work, the staff must understand how to make the patient understand the new system, he points out. "Admitters need to have these conversations, share this information, and they have not had to ask for money historically. They now need to be current [for example] on the Fair Debt Collection Practices Act, [a federal law] which mandates what one can and cannot say or ask for in the process of collecting a debt."
The challenge comes from the fact that people understand health care coverage less than any other insurance coverage they have, says Scripps access director Mollie Drake, MBA, who oversees staff training and development as well as the scheduling and eligibility projects. (See related story on staff training, p. 28.)
"We’re finding it’s not really a collection matter, that we’re actually doing the patient a better service by educating them upfront," Drake says.
"Where collection is tough is when the patient is not aware and gets a bill," she says. "Our surveys tell us they find it very confusing and feel it’s the hospital’s responsibility to figure it out. They’re paying the premium [for insurance], but they didn’t make a conscious decision to buy it — the employer decided on that."
Because the patient didn’t pick the insurance and, oftentimes, didn’t pick the physician, the hospital, or what the physician ordered, the patient feels out of control in the situation, she points out.
Additionally, "the rate they’re expected to pay usually is not based on the total hospital bill, but on the contract with their insurance company," Drake says. "They have a contract with the insurance company, but we have another contract with the insurance company. There needs to be a go-between to explain how they work together."
The patient may have a copayment of 20%, but if the case is being handled on a per diem rate, he or she has no way of knowing it will be paid differently, she says. Many patients get angry when they receive a $500 hospital bill — because they had a deductible — two months after the service and after the hospital has settled with their insurance company. "Our expectation is that it will be paid in 30 days, and at this point, the patient has no option," she says. "They can’t go back to the physician and say they won’t have the procedure."
Explaining options upfront
Under the new system, the idea is to eliminate that kind of miscommunication by having an access representative present all the patient’s options, including payment expectations, at the time of scheduling, Drake says. With some 1,000 outpatients a day spread out among clinically trained employees doing scheduling in the various service areas, that had not been feasible before, she says. "All that [clinical] person cared about was getting the technician, the treatment room, and the right [medical] instructions. They weren’t even accessing the database to get the address or insurance."
By the time access management got involved, 24 to 48 hours before the appointment, "there was rarely enough time to register the patient, call the patient, get the insurance authorization, and maybe get back to the patient," she says. "Even if you did get back, it’s after the appointment’s been scheduled and now you’re calling to say, Can you bring $500 with you?’ Then the patient may not show up because he can’t pay, and you’ve wasted resources. The time to do it is when [the patient] is calling to schedule."
Having the financial conversation with the patient upfront also allows the hospital to identify charity cases right away rather than months later after the patient has been subjected to the collections routine, Drake points out. "That saves effort on the back end and allows the patient to go in [for the procedure] with more comfort."
Realizing she couldn’t find a computer scheduling system that could show a clinical person how to understand financial information, Drake decided to go in the other direction: She would start with a financially trained employee and buy a system that walked that person through the clinical aspects. "With outpatient services, most protocols are standard," she says. "You can build them into the system."
Scripps is in the process of adding the Eclipsys scheduling system to the patient accounting, patient registration, and medical records modules it already uses from that vendor, Drake says. Procedures and protocols are being loaded into the system in phases, with most of radiology on-line by mid-January, physical therapy and speech therapy to follow, and then endoscopy, she adds.
The remainder of the outpatient areas will be brought on-line after that, with the entire system expected to be in place by the end of 2000.
Initially, each of five hospitals will centralize scheduling within its own facility, Drake says. The sixth Scripps hospital is not included in the project, she explains, because it has close ties with one medical clinic that prefers to control its own scheduling.
As soon as Scripps goes to the Eclipsys multi-entity format — an upgrade that allows an access representative to sign on to Scripps as a system rather than to one individual hospital — scheduling will be centralized throughout the system, she adds, and patients will call one number for all facilities.
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