Optimizing Pre-Service Collections Presented by Michelle Tremé

Pre-service Collections Improve Patient Satisfaction and Overall Financial Health Patients appreciate knowing their estimated cost of services in advance so they can focus on their health. Reduces bad debt, because patients are more likely to make better financial decisions when they can plan for the expense before they actually incur it. Cuts down on the billing resources hospitals use to collect after services are rendered. Patients who are unable to pay can be identified early in the account cycle, allowing time to meet with a financial counselor. No surprises about the cost of services enables patients to make more informed choices; like possibly defer non-urgent services, or decide a non-urgent service is cost prohibitive and explore alternatives with their physician.

“More than 8 in 10 Americans report that upfront cost estimates would have a positive impact on their decision to continue using a provider.” Source: TransUnion Healthcare “New findings on consumers’ views of billing experiences and what they mean for you”

Outside Forces Affecting Hospital Revenue Cycles in the Near Future

Source: USA Today “Dilemma over Deductibles: Costs Crippling Middle Class”

Common Excuses for Not Collecting… “Staff doesn’t have time” “Staff has trouble reading benefits from the 271” “Not sure what portion of the benefits may have been met already” “Cannot collect co-insurance because we don’t know our contract rates with payers” “The staff is not comfortable asking for money” “Our patients wouldn’t pay anyways”

Financial Clearance Policy

Discounts, Deposits, and Payment Plans Do you offer Self-pay discounts? Do you offer Prompt pay discounts? What is an acceptable deposit amount for a high dollar estimate? What are your Payment Plan guidelines?

Scheduling How far in advance do you want to schedule non-urgent services? Pre-Authorizations High Dollar Time Consuming Add-On Volumes Add-ons under 48 hours prior to service cause… - Less time to determine benefits - Less time to contact the patient to collect

Scheduling How should a Scheduler handle non-urgent underinsured and self-pay patients? Require clearance from financial counselor Check propensity to pay

Source: The Academy of Healthcare Review “Patient Access Benchmarks” Scheduling Will a non-urgent service be scheduled if the patient cannot meet their financial responsibilities? Source: The Academy of Healthcare Review “Patient Access Benchmarks”

Scheduling What information is required to be collected at the point of scheduling? Demographics Insurance and coordination of benefits Procedure codes and diagnosis codes Pre-authorization information

Pre-Registration / Registration Days Out How far in advance of the date of service should pre-registration occur? Average = 5.3 days Monitor and control daily add-ons to increase pre-registration days out

Pre-Registration / Registration Insurance Verification Expectations for verifying insurance eligibility and benefits? Verify benefits for ALL payers? Or, just eligibility in certain instances? Medicare Medicaid What tools are used to verify benefits? Integrated Verification Tool Payer Websites Phone

Pre-Registration / Registration Estimates How are estimates calculated? Methods Tools Discounts Will you collect estimates over the phone during pre-registration? Or, prompt the patient to bring the payment at the time of service? 73% of surveyed hospitals attempt to collect estimates during pre-registration (Healthcare Business Insights: “Best Practices in Patient Collections”) Conveying estimates prior to the date of service informs the patient and allows multiple opportunities to collect.

Pre-Registration / Registration Payments Will partial payments be accepted? Will staff attempt to collect outstanding balances on prior services? Can registrars set up payment plans? “Yes” to all of the above allows opportunities to increase collections, reduce A/R, and prevent bad debt.

Pre-Registration / Registration Medicare Medicare Secondary Payer and other dual eligibles? Not beneficial to collect up front from patients with more than one active coverage. What is the process for when Medical Necessity fails and an Advanced Beneficiary Notice is issued? Prompt the patient for payment Refer to financial counselor

Financial Counseling Under what circumstances should a financial counselor be contacted? Who should contact them? And when? Financial Counselors should be contacted by staff as soon as the need is identified. Patients that are given instructions to call the financial counselor often times never call. Should the Financial Counselor collect payments due from non-urgent financially capable uninsured and underinsured prior to clearing the patient to be scheduled? Yes. Follow organization’s outlined procedures regarding discounts, deposits, and payment arrangements.

Financial Counseling Financial Counselor Assistance Healthcare Exchanges / Affordable Care Act Medicaid Eligibility / Presumptive Medicaid screening Charity Care Patient Friendly Loan Programs Payment Plans

Financial Clearance Policy Implementation Administration Approval Critical that pre-service collections is part of a formal hospital policy Support of the policy from the board, CFO, and other leadership impresses the importance of the process to staff across all departments in the organization. Policy enforcement is important, even if a patient complains.

Financial Clearance Policy Implementation Communication! Remember that a pre-service collection policy may be a culture change for the hospital staff, as well as patients. It may take a little time, but the culture will start to shift. Patients will expect to pay in advance, and many will actually embrace it.

Financial Clearance Policy Implementation Communicate the Policy Patient Access Staff E-mail updates Regular staff meetings Periodic Training Performance expectations and goals Request Feedback

Financial Clearance Policy Implementation Communicate the Policy Hospital Departments and Physician’s Offices Gain support by explaining how up front collections effects the entire revenue cycle and benefits the whole organization. Both areas can be very helpful with setting expectations for patients to be asked for payments before services are rendered. Coordination between supervisors and departments can quickly identify process breakdowns.

Financial Clearance Policy Implementation Communicate the Policy Public Newspapers, hospital website, signage, and brochures Include acceptable forms of payment Consider sending letters or e-mails to pre-registered patients informing them of their estimate and payment options

Tools for Collecting Benefit Verification Price Estimation Payment Processing Kiosks

Tools for Collecting Benefit Verification Integrated Eligibility Tools Accurate benefit verification of most common payers Response time under 30 seconds Easy process flow when integrated in registration pathways Allows for a seamless flow of information into a price estimator Payer Websites Good for payers that cannot be accessed by the integrated verification tool Serves as a back up if integrated system is experiencing problems Supervisors should maintain logins for everyone that verifies insurance. Be sure to terminate the login when employment ends. Phone Not the ideal method to verify benefits, but serves as a good back up Keep a list of payer’s current phone numbers stored in a shared document that can be easily accessed

Tools for Collecting Price Estimation Software Easily calculate estimates for co-pays, deductibles, and co-insurance Loaded with data files of organization’s CDM and payer contracts. Data feeds from your registration software enables the automatic flow of information into the estimate, like demographics and insurance information; as well as benefit information like co-pays, co-insurance, and any remaining deductible and Out of Pocket amounts. Provides a summary letter of the estimate that can be printed or e-mailed to the patient.

Tools for Collecting Web-based Payment Processing / E-cashiering Easy for Pre-registration staff to take payments by phone Possible for patients can make payments online Receipts can be e-mailed or printed at the time of payment Integrated payment platforms allow patient payments to be linked to registration and accounting mechanisms; therefore payments can be posted immediately.

Tools for Collecting Kiosks Increases collections by requesting and accepting payments Offers the option for patients to pay outstanding balances Reduces wait times and speeds up the check-in process Patient forms are signed electronically

Training Educate staff about the importance of pre-service and point of service collections as it relates to the financial health of the organization. Financial Clearance Policy training. Test staff knowledge on how to read and interpret eligibility responses. Customer service skills. Note everything! “If it’s not documented, it didn’t happen!”

Training Make sure collectors have a thorough understanding of key terms, including: contract rate, in-network, out-of-network, co-pay, deductible, co-insurance, and out-of-pocket. Increases confidence, thereby making it easier to collect. Test staff by calculating estimates manually.

Sample Estimate

Sample Solution Allowable Amount $2000 – Deductible $500 = $1500 $1500 x Co-Insurance Rate 20% = $300 Remaining Deductible $500 + Co-Insurance $300 = $800 Prompt Pay Discount = $800 x 10% = $80 $800 - $80 = $720 Patient Responsibility = $720.00

Training Scripts Create a flow chart for staff to follow when attempting to collect that includes different scenarios. Be sure to over-emphasize the word “ESTIMATE” during training. Never use words like “quote.” Teach staff to use a disclaimer, “Your Estimate is based on hospital charges for the scheduled procedure. You may be billed for any other charges that apply.” Provide scripting to all staff that interacts with patients on how to respond to questions or complaints about pre-service collections.

Training Scripts Use phrases that encourage the patient to make a payment. “Based on your insurance coverage and the scheduled procedure, your estimated amount due is $200.00. We accept Visa, MasterCard, Discover, and electronic check payments. How would you like to take care of that today?” Opposed to, “Would you like to pay today?” “Since you will not be paying over the phone today, how will you be paying at the time of service?” “Since you cannot pay your estimated amount due, how much can you pay today?” “It is now our hospital’s policy to collect estimated amounts due prior to the time of service. It helps us better serve our patients by informing them of their estimated responsibility, and it cuts down on our billing costs.” Do not communicate a minimum amount due until you have exhausted other options.

Training Scripts Role Play Role Play with different scenarios until staff feels comfortable with scripting. Let staff members challenge each other. Meet with staff regularly, and openly engage them to share scripting ideas based on their interactions with patients. Include scripting in new-hire training.

Reporting and Monitoring Continuous reporting and monitoring on a monthly, weekly, and even daily basis is key to success. Share reports with your staff regularly to show them you are paying attention, and convey the significance of what you’re monitoring.

Reporting and Monitoring Set performance goals that are measurable and attainable. Base goals on industry and organizational benchmarks. Amount Collected vs. Amount Available to Collect for each registrar Number of accounts with available collections vs. number of accounts collected Pre-Service Collections vs. Point of Service Collections Pre-Registration Days Out, track and trend over time. Add-ons per day Insurance Verification Rate = Registrations with Insurance Verified / Total Registrations Pre-Registration Rate = Total Pre-Registrations / Total Scheduled POS Collections as a Percentage of Net Revenue

Pre-Service Collections Vs. Point of Service Collections

Scheduling Trends / Add-On Volume Tracking

Reporting and Monitoring Incentives Recognition, gift cards, free lunch Consider incentives for meeting goals, and higher incentives for surpassing goals Apply a team incentive approach which encourages individual participation Share performance scores to create friendly competition Realize that goals must be adapted for each area or shift Ask for feedback about which incentives are most encouraging

Tips for Success Accountability - Hold supervisors accountable for their staff’s performance, as well as the individual staff members. It helps create a culture of high performance standards. Standardize collection efforts across all of your organization’s sites to ensure patients are provided with a consistent experience. Handling staff members that are resistant to performing pre-service collections because they feel uncomfortable: Let them know collecting is a requirement of their job. Update the job description if collecting is not already included. Staff should sign off that they have been made aware of any new policies, processes, or procedures. Offer more training and practice sessions.

Tips for Success Don’t get caught up exceptions! Pre-service collections should not be an “all or nothing” strategy. If your organization is not able to call to pre-register and collect estimates from all scheduled patients due to staffing issues, consider prioritizing patients scheduled for high dollar services.