Patient Estimator Facility View

Leah Klinke

Director, Patient Financial Services

Agenda

• Industry Changes in Self Pay• Our Journey to Price Transparency• Successes• Additional Opportunities

INDUSTRY CHANGES Price Transparency

Changes in Self Pay

• More patients are covered• Through government programs like Medicaid and

CHIP• Through commercial coverage available through the

marketplace

• Insured patient remaining balances are increasing • Higher deductibles• Higher share of cost (coinsurance)• Coverage and tiering restrictions

Out of Pocket Expenses on the Rise

Blue Cross Commercial$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

Day Surgery

2011201220132014

Out of Pocket Expenses on the Rise

Blue Cross Commercial$0

$1,000

$2,000

$3,000

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$6,000

Inpatient

2011201220132014

Decline in Collectability

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$0-$250 $250-$500 >$500

*WVUH Data - Balance after Insurance Only

The higher the balance, the less collectable

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Effort Shift to Insured Patients

2011 2012 2013 2014$0

$20,000,000

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$60,000,000

$80,000,000

$100,000,000

$120,000,000

True Self Pay

Balance After Insurance

Changing Focus

• How do we focus on speeding up payment for balances after insurance?

• How do we increase collectability on balances after insurance?

• Could patient education prior to service change a patient’s payment behavior?

• We decided to give it a try – ICD-10 gave us the justification.

OUR JOURNEYPrice Transparency

Our Plan of Action

• Implement a tool to estimate a patient’s out-of-pocket expense prior to service

• Engage the patient prior to service to educate them about their financial obligation

• Collect a deposit on that obligation• Inform patients of our payment options, including

prompt-payment discounts and payment plans, prior to service

• Increase patient collections on insured patients

Exploring Options

• In 2012 & 2013 we met with a number of vendors who provide patient estimator tools

• Priorities:• Combined physician and hospital estimate• Incorporate actual patient benefit levels• Must be accurate• Should produce a letter that was easy for the patient• to read• The estimate letter must be available for viewing• downstream

Redesigning Financial Counseling

• With the reduction in self pay, the need for traditional role of Financial Counselor position was decreasing

• Goal was to keep existing positions, even with self-pay down 65%

• Attempted to re-define Financial Counselor to be more relevant to the current market

Tool Selection

• Were leaning toward a vendor who we already work with for eligibility

• Explored EPIC’s estimate tool and found that it did most things that we wanted it to• Was not as user friendly as the external tools• Did not require the system interfaces required by

external vendors• Believed that accuracy would be comparable• Tracking of estimates and collections would need to be

built• No cost to implement

Tool Implementation

• EPIC’s tool was not widely used, so there was some trial and error to the process

• Worked with faculty practice to make sure that file feeds were built accurately

• Developed estimate letters with the input of the financial counselors

• Decided to focus on Day Surgery first as it was the highest opportunity and simplest workflow

How It Works

1.Estimates Expected Charges

• Hospital – • Historical Case - complicated cases such as surgeries • Per Charge Price - line item charged items such as

radiology and lab services

• Physician – • Planned procedures entered• Suggested add-ons based on history (e.g. pathology,

anesthesia)

How It Works

2. Estimates Expected Allowable –

• Hospital – • The system uses either our programmed contract terms or

historical pricing to come up with the expected allowable for the average case

• Physician – • The system applies the actual fee schedule to the charge

based on the payer

How It Works

3. Estimates Patient Benefits

• Based on an electronic eligibility response, current benefit levels are applied to determine the patient’s expected out-of-pocket for the visit.

How It Works

4. Estimate Letter is Produced

• Letter displays expected charges, allowable, and out of pocket

• Letter instructs patient on payment options and potential discounting

How It Works

4. Estimate Letter is Produced

• Displays expected charges and out of pocket 

• Instructs patient on payment options and potential discounting

How It Works

5. Financial Counselor Communicates Estimate to Patient

• Financial counselor calls patient to communicate estimated out-of-pocket expense

• Discusses payment options and requests a deposit in advance

• No advance payment plans at this time• No delay or cancelation if patient refuses to pay in

advance

Financial Counselor Concerns

• Accuracy of Estimates• Did not understand billing & charge variation

enough to explain the estimate to patients• Not experienced at collection conversations with

insured patients (vs. uninsured patients needing financial clearance)

• Did not understand patient benefits well enough to explain to the patient

• Concerned that patients may opt out of services

Testing for Accuracy

• Testing Charge Levels:• Took some high volume procedure and tested EPIC’s

estimate against actual averages from an external data source.

• Reviewed results to determine how close we came to the actual average charges

Sample Test: T&A

Series1

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000 EPIC Average: $5,671 (w/ outliers)

$ 5,540 (w/out outliers)External Average: $5,585 (w/ outliers)

$ 5,386 (w/out outliers)

Testing for Accuracy

• Testing Contract Expected:• Viewed sample cases and reviewed against stand-

alone models for contract expected• Found that the tool only calculates expected for actual

claims for that payer in history (on hospital esimtate), which makes pricing sample smaller than charge sample

• Provided financial counselors with a “cheat sheet” of contract expected so that they could utilize if no history was found.

Testing for Accuracy

• Testing Benefit Levels:• Took sample cases that had already processed and

checked the estimate against what the patient’s actual out-of pocket

• Found that accuracy of benefit levels were more important than charge level estimates for high dollar surgical cases

• Many nuances to benefits that are not picked up with electronic eligibility that caused some accuracy problems (e.g. individual vs. family OOP limits, is deductible applied before or after coinsurance?)

Education

• Prepared some slides on charge variation to explain how charges varied from case to case

Education

• Hired external group to come in and conduct shadowing and training on how to educate the patient on their out-of-pocket liability

• Participated in role playing conversations to bring up scenarios and discuss possible responses

• Provided reference tools and optional scripting to assist in formulating the conversation

SUCCESSESPrice Transparency

Collectability is Increasing

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$0-$250 $250-$500 >$500

*WVUH Data - Balance after Insurance Only*2015 (est) = annualized Q1 results

Based on Q1 results, we are having more success collecting balances in 2015

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Success of Payment Plans

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Pmt PlanNo Pmt Plan

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Collectability is higher when patients commit to payment plan at any balance level

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*WVUH Data - Balance after Insurance Only

Payment Plans on the Rise

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$0-$250 $250-$500 >$500

Payment plans have increase, especially at higher balance

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*WVUH Data - Balance after Insurance Only*2015 (est) = annualized Q1 results

ADDITIONAL OPPORTUNITIESPrice Transparency

Opportunities

• Expand to other areas (e.g. radiology)• Continue to increase pre-service collections• Increase payment plan commitment • Set up auto-pay payment plans