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A Roadmap toThe Patient Financial Experience of the Future

Part III of a Five Part Series

HIMSS Revenue Cycle Improvement Task ForceFebruary 2018

Sponsored By:

EXECUTIVE SUMMARY

In March of 2016, HIMSS published the first of this five-part series, entitled A Roadmap to the Patient Financial Experience of the Future. The initial paper considered the technology required to realize the HIMSS Revenue Cycle Improvement (RCI) Task Force’s vision of the Patient Financial Experience of the Future.

The following year, HIMSS published the second paper which examined the patient financial experience from the view of physician and non-physician providers, collectively referred to as providers. The paper analyzed the back-office revenue cycle management (RCM) functionality required at the provider level to facilitate the task force’s vision of interoperability and seamless claims processing. Now, HIMSS provides a detailed view of the patient experience in the hospital setting, examining new models and technologies and taking into account the challenges they present in the revenue cycle of a complex hospital organization. Similar to previous publications in the series, this paper follows the patient’s journey from pre-care, through treatment and coordination of care, ending with patient satisfaction. The focus is on coordination and interoperability of systems and processes related to in-patient care. The paper identifies gaps between business processes and systems that exist today, and those required to realize the task force’s vision for the future.

Realization of the Revenue Cycle Improvement Task Force’s vision of the Patient Financial Experience of the Future will require widespread adoption of a full range of tools to support the complete patient hospital episode, from the point at which a hospital admission is scheduled, through the check in, inpatient care, check out and finally, settlement of the payment by both the insurance company and the patient. These tools will need to be fully integrated, and allow bi-directional information flow to simplify and improve the patient’s experience.

As the RCI task force considered the implications of a more patient-centered approach to revenue cycle management in general and began articulating a proposed vision for improving the patient financial experience, the healthcare industry and consumers were simultaneously realizing the challenge to be even greater than originally expected and the solutions much more complicated.

Hospital Gap Analysis White PaperNovember 1, 2017 of 22© Healthcare Information and Management Systems Society

Realizing the task force’s vision of the Patient Financial Experience of the Future will require widespread adoption of a full range of tools.

http://www.himss.org/library/health-business-solutions/journey

http://www.himss.org/roadmap-patient-financial-experience-future

http://www.himss.org/roadmap-patient-financial-experience-future

Emerging technical capabilities, cultural shifts, and an increase in patient financial responsibility are changing the dynamics of the patient-provider relationship, including patient decisions on which hospital to use in those circumstances where services may be planned in advance. The growth in consumer financial responsibility – through both direct increases in costs of plan premiums, ever-increasing financial responsibility shifting to the consumer from the employer and the prevalence of high deductible plans - has caused the patient to become more careful and cost conscious when making healthcare treatment choices.

In the inpatient hospital setting, this decision making process grows even more complicated because of the variety of providers who will care for the patient during their stay and the fact that some providers are in network with the patient’s health insurance plan, and some are out of network. A patient may be unaware that although the medical or surgical provider and hospital they’ve chosen is in network, the radiologist or pathologist responsible for reviewing images or lab work is not. This leads to surprise billing experiences. Under the vision for the Patient Financial Experience of the Future, this becomes a thing of the past. Patient engagement begins early in the process, and contractual relationships between all of the providers involved in a patient’s plan of care and the patient’s insurance carrier are disclosed as part of the planning process.

Confusion caused in large part by the lack of interoperability of systems and technologies is a major contributor to patient dissatisfaction. Hospitals are aware that patients are becoming more directly involved in choosing where they will receive hospital care. These decisions are generally based on the patient’s preferred physician’s affiliation, but may also include consideration of the level of price transparency provided by the hospital, perceived value in both services and amenities, and the degree to which the patient overall hospital experience is effortless and integrated. Patients are purchasers and are rightfully demanding value. They expect hospitals to find solutions to streamline admissions, reduce duplicate data collection and data entry, eliminate administrative errors in registration and insurance authorizations and reduce the overall cost to the patient and the system.

The current technology solutions between payers, providers, and financial institutions are insufficient to reduce costs and improve patient experience. Progress has been made within individual hospitals and their integrated providers, but there is a general lack of integration and interoperability across hospitals and providers. Data sharing is inefficient to support the level of process simplification necessary to truly reduce costs and improve patient experience. The reasons for the lack of integration are as varied as the systems in the market which have little or no connectivity and bi-directional data flow, as well as the general absence of a strong driver for change.


In the Patient Financial Experience of the Future, patient engagement begins early and the contractual relationships between all of the providers involved in a patient’s plan of care and that patient’s health plan are disclosed as part of the planning process.

There are already a number of examples emerging across the industry of significant efforts to improve components of the patient financial experience. However, even broader industry engagement in the envisioned goal and commitment to the level of secure data sharing and interoperability is essential to enable the optimal consumer-friendly revenue cycle and provide for the financial wellness of our healthcare delivery system.


I

It is the vision of the HIMSS Revenue Cycle Improvement Task FPorce to improve the patient financial experience by improving the business processes and technical functionality that support it.

ROADMAP TO THE FUTURE

Category I: Pre-CareAs a result of the patient’s interaction with a primary care physician or a specialist, a clinical need for inpatient care has been identified by the physician and the patient has agreed to the inpatient service(s). To support this activity, patients need access to information from the hospital(s) where the physician has privileges. Hospitals need to provide electronic access to enable patients to identify the scope of services provided, geographic locations, health plans in-network, billing and payment policies, including financial assistance policies, and quality and patient satisfaction ratings.

Patients tend to choose their hospital provider based on their specific physician’s privileges and their health plan. Tools that provide a technical connectivity solution with the ability to determine and match the details of the health plan, such as the provider network, healthcare benefits, deductible and co-insurance with the patient’s healthcare needs and geographic location will simplify this task. Critical to this process is the hospital’s ability to provide meaningful pricing information based on the treatment options suggested by the physician.

In the Patient Financial Experience of the Future, the ability to electronically schedule hospital services and exchange patient demographic, medical and financial information will streamline the registration process when the patient arrives for admission. A single point solution where the patient’s medical information, including clinical documentation supporting the reason for admission will allow dissemination of information between the patient’s physician and hospital staff who use that information to complete any required managed care processes, including pre-authorization for service. Alternately, the hospital will capture all prior authorization work finalized by the physician’s staff. The customization of these electronic tools is an important shift in focus from the providers (physician and hospital) to more efficient processes that support both the patient and the providers.

While there are progressive technology solutions available today that deliver pieces of


Source: HIMSS Patient Financial Experience of the Future Infographic

http://www.himss.org/library/health-business-solutions/patient-financial-experience-of-the-future


this vision, no one solution provides a seamless, patient focused solution for the functionality described here.

As a part of the scheduling and reservation, the hospital creates an electronic price estimate for professional and hospital services, including the availability of financial counseling and financial assistance as appropriate. This process will provide real-time estimates as requested, payment options, payment processing prior to service, and availability of financial counselors to discuss all applicable options, including financial assistance. The hospital also communicates the network status of all physicians and associated providers (for example, CRNAs) who may be involved with the patient’s care.

Based on the estimate provided, the patient chooses how the financial responsibility will be resolved. The resolution is recorded in the hospital’s patient financial system. Options range from payment in advance of service through structured payment agreements and financial assistance, based on the patient’s need and available resources.

The hospital electronically receives orders from the attending physician for any medically necessary preadmission testing. Diagnosis and testing information is translated into the appropriate codes required for generation of the required claim data. The hospital electronically schedules the required testing, and, upon completion, electronically updates the patient’s electronic health record and notifies the attending physician, the PCP, and other members of the care team as necessary with the testing results. Information provided to the patient will include disclosure of the patient’s anticipated financial responsibility, if any, for these pre-treatment services.

The following table lists specific gaps in currently functionality that will need to be filled for pre-care activities to flow as seamlessly as described in this section.


Functional Components GapsIdentified Functional Solutions

Category I: Pre-CareElectronically available pricing information that allows calculation of total estimated price for hospital stay, including all anticipated services and supplies from pre-service through discharge

Ability to select exact plan and automatically apply both current benefit status, calculate payer and patient liabilities based on adjudication of estimated claim in real-time

Various estimator tools are provided by payers based on benefits and average costs of care

Mobile or web-based electronic tool to look up hospital’s pricing, discounts and financial assistance for self-pay patients

Application to incorporate price estimation and discount/financial assistance rules for calculation of financial liability for uninsured or underinsured patients

Some provider-specific tools have been developed but overall use of mobile tools is still very limited

Patient selection of payment plan, as applicable, and establishment of plan terms within the patient accounting system

None Functionality exists in patient accounting systems and patient portal systems for electronic processing of payment plans

Automated pre-authorization processing between hospital and payer using electronic standards

Standards exist, however, implementation is fragmented; EHR integration into the process is generally lacking

Provider negotiated and payer specific solutions involving payer direct access to EHR is developing with select payers

Preadmission testing ordered electronically via secure mechanism and scheduled within hospital departments’ systems

Interoperability between physician and hospital systems if disparate systems

EHR functionality

Patient completes testing; hospital creates claim and receives payment for pre-admission services

None Varied mechanisms in place for payment receipt and processing of payer and patient payments


Category II: Admission ActivitiesThe task force envisions a future in which hospitals will utilize an automated arrival and check-in process. The task force is aware that there are a limited number of automated solutions available in the market today, but we are not familiar with one that provides a fully automated process for this arrival processing. As with the on-line registration process and sharing of information, developing this type of solution will require the creation and adoption of national standards and uniform operating rules related to patient matching to ensure that the right information is being associated with the right patient. Electronic awareness and connectivity by means of a variety of technologies to expedite the arrival process is another step in moving the patient into the forefront of the streamlined admission process.

During the arrival process, the patient’s identify is confirmed, and using available electronic systems, the patient financial and medical records are updated. It is the task force’s vision that the hospital will have real-time access to the patient’s healthcare benefit information, including any patient financial responsibility associated with the current admission, such as deductibles and/or co-insurance, the provider network associated with the patient’s health insurance coverage, and pricing information for the services to be delivered. It is further expected that the hospital will be able to share that information in a meaningful way with the patient to ensure understanding of previously provided financial responsibility information. The hospital will also be able to provide applicable information about payment options for the patient’s financial responsibility, and be able to facilitate payment arrangements at the time of admission.

The challenges in realizing this vision for the future are two-fold. The current healthcare system lacks both the technical ability to share the level of detailed information identified herein and the business processes to support the scenario described. There are cultural challenges as well. Many hospitals are not accustomed to incorporating comprehensive financial responsibility education as part of the admission process. While ideally this information sharing happens prior to service, updating and confirming, financial information at the time of admission is an important patient-focused activity. The hospital’s challenge is to provide tools that facilitate the sharing of financial information in an automated, real-time fashion with the patient based on the inpatient service ordered by the patient’s physician.


In the task force’s vision for the future, the hospital will have all of the patient’s clinical, insurance and financial information already transferred into their system before the patient arrives for treatment.

Category III: In-Patient ActivitiesUpon completion of the admission activities, the patient receives the medically necessary services prescribed by the attending physician. Using the electronic medical record, the caregivers record all services which form the basis of the claims to be submitted for payment. Concurrently, discharge planning activities, including coordinated post-discharge care, are undertaken to assure compliance with and no adverse financial impact to the care delivery and payment model in place. Key to these activities is the availability of a secure, electronic mechanism to store and share information with the admitting physician, the primary care physician, caseworkers, social services staff, as well as with the patient.

Avoiding duplication of services and unexpected costs for the patient requires that all providers document and capture a patient’s inpatient plan of care electronically, and that the plan of care is shared with the patient and all providers involved in the execution of that plan. As previously noted, there is no widespread adoption of business processes and tools that support the secure exchange of clinical, quality and financial data among the different providers and payers who may be involved in the patient’s inpatient service. This is true for providers within the same system as well as disparate providers who are also involved with the patient’s care during the inpatient admission.

In addition, health plans must find a way to determine and communicate patient financial responsibility in real-time for this vision to be realized. The goal should be a redesign of benefit structures created to support alternative payment models. This redesign would make it easier to predict patient financial responsibility related to claims adjudication. Technical solutions aimed at providing real-time claims information among all affected parties will be fundamental to this innovation

The following table lists specific gaps in current functionality that will need to be filled for inpatient care activities to flow as seamlessly as described in this section.



Category III: In-Patient ActivityTranslation of clinical records into appropriate codes to meet claim data requirements

No widespread adoption of business processes and tools that support the secure exchange of clinical, quality and financial data between different providers – both within the same system and disparate systems-involved in the same inpatient admission

Product that will be interoperable with the EHR/EMR and patient clinical information across the spectrum of care providers

Initiation of discharge planning to assure compliance with and no adverse financial care impact to care delivery/payment model

Secure mechanism to store and share information amongst caregivers and apply financial impacts to various post-acute care options, as appropriate

Currently limited interoperability for secure information sharing within individual systems

Category IV: Discharge Planning For those inpatient episodes of care requiring follow up care or a referral to another provider, it will be the norm for the transition of care to be coordinated by the hospital, ensuring the patient is well prepared for their engagement with these activities before the patient leaves the hospital. All applicable patient information will be automatically shared between providers without the need for patient facilitation. While the major EHRs assist with this functionality to some extent, there is still a lack of a universally adopted scheduling tool and wide spread information exchange, especially between non-affiliated providers.

Additional coordination will be required to ensure that the post hospital services are included in the care delivery/payment model covering the patient’s hospital and post-acute care services. Special attention will be given to ACO models, bundled payment programs and other risk-based programs.

The discharge planning process will also allow hospitals to use tools that ensure consolidated financial and clinical information will follow the patient throughout their inpatient care and include real-time updates as they occur. The financial implication of this capability is that shortly after the patient is discharged from the hospital, the hospital is able to provide one final consolidated bill that includes charges from all providers involved in the episode of care, and clearly states the patient’s total financial responsibility. Having provided an estimate of the financial responsibility at the time treatment was chosen, the hospital will equip the patient to reconfirm any payment arrangements completed earlier in the process.


The following table lists specific gaps in currently functionality that will need to be filled for discharge planning activities to flow as seamlessly as described in this section.


Category IV: Discharge PlanningTools to engage patient in understanding financial impacts of post-acute care activities, as appropriate that are in accordance with applicable care delivery/payment model

Interoperability between disparate EHR systems

Some bolt-on tools exist for secure exchange of patient information

Update patient on current charges and financial responsibility at discharge

Lack of real time charging, coding and claim processing; real time claim adjudication

Applications exist to create claims but not in real-time at point of discharge

Reconfirm account resolution arrangements, if applicable

Lack of real time charging, coding and claim processing; real time claim adjudication

Applications exist to create claims but not in real-time at point of discharge

Category V: Care Coordination (If Applicable)Based on the completion of the discharge planning process, in the Patient Financial Experience of the Future, the hospital will collect and incorporate all the patient’s financial records and clinical information required for care delivery and payment along a continuum of post-acute care services. Activities will include the secure transfer of electronic financial and clinical information, payments, receipts, authorization information among all providers expected to provide post-acute care services.

The following table lists specific gaps in currently functionality that will need to be filled for coordination of care activities to flow as seamlessly as described in this section.



Category V: Care CoordinationCollect and incorporate patient financial information into patient’s financial records as required for care delivery/payment model and to create continuum of financial information for patient billing activities to allow secure movement of financial information among post-acute providers

Disparate systems limit secure electronic transfer of financial information; type of payment model in effect may not be supported by current systems

Limited availability of applications that work across disparate systems and payment models

Category VI: Final Billing ProcessFollowing the patient’s discharge from inpatient care, the hospital completes the accumulation of all charge and clinical information required for accurate completion of the electronic claim(s) and submits the claim(s) to the appropriate payer(s) for adjudication and electronic payment. Simultaneously, the patient receives the explanation of benefits and/or a patient bill, as appropriate. If the patient has agreed to a payment plan, processing is initiated electronically to implement the components of the payment plan program.

As payments are received, funds are distributed to physicians and others as appropriate, based on the service delivery/payment model in effect. Remaining balances are tracked with the patient’s account resolved within the parameters of the hospital’s account resolution/collections policies and procedures.

The following table lists specific gaps in currently functionality that need to be addressed for the final billing activities to flow as seamlessly as described in this section.


Category VI: Final Billing ActivitySecure mechanism for transmitting final billing information to appropriate payers in the appropriate sequence

Ability to consolidate claims for all hospital and other providers as required under specific payer contracts/payment models

Limited availability of applications that work across disparate systems and payment models


Category VII: Patient FeedbackHospitals realize the importance of patient satisfaction not only with their clinical care, but with the financial aspects of their care as well. In the future, it will be a standard component of the hospital care experience for patients to provide feedback regarding all aspects of their healthcare experience in real-time, or upon completion of the inpatient services. Mobile technology will replace or supplement other feedback methodologies. Feedback collected will include comments regarding all elements of the experience, from ease of identifying the hospital, to the simplicity of the scheduling, pre-service and registration process; to how well the hospital’s tools delivered appropriate financial information, and how and when the patient’s financial responsibility was addressed. This is not a new concept. The Centers for Medicare and Medicaid Services (CMS) has embraced this philosophy in practice through their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey program, which is the first national, standardized, publicly reported survey of patients' perspectives of hospital care.

Currently, individual hospitals and the industry as a whole lack a consistent approach to providing feedback to the care providers regarding opportunities for improvement. The task force believes that for feedback mechanisms to be truly meaningful they must be easy and compelling for patients to participate in, consistent across the industry, constructive criticism must be acknowledged, and patterns must be tracked. Where patterns of extreme satisfaction exist, providers should be rewarded.

The following table lists specific gaps in currently functionality that will need to be filled for patient feedback activities to flow as seamlessly as described in this section.


Category VII: Patient Feedback ActivityReal-time post patient satisfaction surveys sent to all patients via patient’s selected method (email, mail, mobile)

Current survey methodologies generally limited to email or mail surveys

Automated surveys in other industries

Deployment of consistent survey tools and questions to enable identification of best practices

Medicare surveys and provider-deployed surveys not coordinated to create best practices information

Tools used in other industries and research platforms


https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html

EFFORTS CURRENTLY UNDERWAY

Not all of the functionality required to support the Patient Financial Experience of theFuture will need to be created from scratch. The 2017 grids associated with each of the major segments of the Roadmap identified technology gaps and emerging solutions to fill those gaps. The Office of the National Coordinator’s (ONC) efforts as demonstrated through their Consumer Health Data Aggregation Challenge1, the Provider User Experience Challenge2, and the Use of Block chain in Health IT Challenge3 include innovative solutions to many of the gaps identified in this white paper. The solutions/initiatives included in our grid are in no way intended to be a comprehensive inventory nor an endorsement of these solutions by HIMSS. Rather, this step is designed to illustrate movement already underway in the industry, that can be built upon to realize the Patient Financial Experience of the Future, and fill some of the functional technology gaps identified in this roadmap.

CALL TO ACTION

The findings presented in this paper represent the beginning, not the end, of the process. The HIMSS RCI Task Force needs your help to actualize its vision for improving the hospital and patient financial experience. Achieving the task force’s vision will require a paradigm shift among all participants – patients, hospitals, physicians, payers, vendors, and financial institutions. Will you join us and take action to make this vision a reality? Here are a few suggestions of how you can help.

Share your solutions!Does your group have a solution to any of the issues identified in this paper? Are you working with a vendor or have a process in your organization that has solutions for any of the challenges identified in this paper? Have you read about a new company that has solved these challenges? We are looking for authors to contribute thought leadership pieces on any of the topics raised in this paper. Has someone in your organization written an article for a professional journal, a master’s program or perhaps a professional certification? Contact Pam Jodock, HIMSS Senior Director, at [email protected] to share what you know.

1 : https://www.hhs.gov/about/news/2017/01/12/onc-announces-winners-consumer-and-provider-app-challenges-improve-health-information-access-and-use#2 : https://www.hhs.gov/about/news/2017/01/12/onc-announces-winners-consumer-and-provider-app-challenges-improve-health-information-access-and-use#3 https://www.hhs.gov/about/news/2016/08/29/onc-announces-blockchain-challenge-winners.html


mailto:[email protected]

https://www.hhs.gov/about/news/2016/08/29/onc-announces-blockchain-challenge-winners.html

https://www.healthit.gov/newsroom/blockchain-challenge

https://www.healthit.gov/newsroom/blockchain-challenge

https://www.hhs.gov/about/news/2017/01/12/onc-announces-winners-consumer-and-provider-app-challenges-improve-health-information-access-and-use


https://www.challenge.gov/challenge/provider-user-experience-challenge/



https://www.challenge.gov/challenge/consumer-health-data-aggregator-challenge/

https://www.challenge.gov/challenge/consumer-health-data-aggregator-challenge/

Submit a Patient Experience Story The task force is aware that there may be tools or solutions available today, but not widely adopted, that could address specific gaps identified in this analysis. If you have such a solution, or are looking for a partner to pilot one, we encourage you to contact the HIMSS RCI Task Force. Criteria and application forms for Patient Experience Stories are found here.

Accepted stories will be promoted through a variety of HIMSS communication avenues, including professional publications, social media, and maybe even a chance to present at a HIMSS Annual Conference.

Participate in the HIMSS Revenue Cycle Improvement task forceThe Revenue Cycle Task Force is always open to new members. The time commitment is only a few hours per month, but the benefit is much greater. Join your peers and share what you know, learn from like-minded colleagues and help advance the profession. We welcome your input and participation. The only requirement for participation is that you be an active HIMSS member. If you are an existing HIMSS member interested in joining the task force, please contact DonVielle Young at [email protected]. For more information on how to become a HIMSS member, please visit our website.

Join the conversationPlease visit the HIMSS Patient Financial Experience of the Future microsite. After completing the full journey, please share your thoughts and ideas through the link provided on the website, or by emailing Pam Jodock directly at [email protected]. Additional work products can be found on HIMSS Revenue Cycle Improvement web page. Join the HIMSS Revenue Cycle Improvement LinkedIn Group and contribute your ideas.

Spread the wordHIMSS encourages you to share this white paper and the links included herein with your friends and colleagues. HIMSS is honored when someone chooses to reference the work the RCI Task Force as KeyBank did in this example.


http://pages.healthcareitnews.com/rs/922-ZLW-292/images/KeyBank-Revenue%20Cycle%20FINAL%20082616.pdf?aliId=400390336

https://www.linkedin.com/groups/12030137

http://www.himss.org/library/health-business-solutions/revenue-cycle-resources




http://www.himss.org/membership




CONCLUSION

Healthcare is an ever changing, complex system that requires ongoing efforts to optimize the experiences of the patients and healthcare professionals caring for them. The work represented by this paper is an example of the need to continually challenge the status quo, to innovate finding better ways to improve process and healthcare outcomes.

The HIMSS RCI Task Force Patient Financial Experience of the Future imagines a day when automation and system interconnectivity eliminate the need for multiple administrative processes related to an inpatient hospitalization. The vision encompasses patients having all of the information they need – clinical, financial, and health plan benefits - to effectively partner with their physician and hospital in determining the best treatment options for their specific circumstance. A simplified consolidated billing process must replace multiple bills and explanation of benefits with a single, easy to understand on-line statement that provides up-to-the minute charges for the patient’s review and multiple electronic methods for paying their portion.

The purpose of the HIMSS Revenue Cycle Improvement’s Roadmap to the Patient Financial Experience of the Future series is to highlight the opportunities associated with realizing the task force’s vision of the future, and to acknowledge the work already underway that will lead us to that vision. Systems are becoming more connected. National registries and interconnected hospital and physician medical records are becoming the norm. Connectivity across practices and hospitals is being more seriously considered than ever before as a way to reduce administrative costs and improve the overall patient experience.

Realization of the task force’s vision of the Patient Financial Experience of the Future will require widespread adoption of a full range of tools to support the complete patient hospital episode, from the point at which a hospital admission is scheduled, through the check in, inpatient care, check out and finally, settlement of the payment by both the insurance company and the patient. These tools will need to be fully integrated, and allow for bi-directional information flow to simplify and improve the patient’s experience.

“Here’s to the crazy ones. The misfits. The rebels. The troublemakers. The round pegs in the square holes. The ones who see things differently. They’re not fond of rules. And they have no respect for the status quo. You can quote, disagree with them, glorify or vilify them. About the only thing you can’t do is ignore them. Because they change things. They push the human race forward. And while some may see them as the crazy ones, we see genius. Because the people who are crazy enough to think they can change the world are the ones who do.”

Ron Siltanen


APPENDIX


BACKGROUND

Revenue cycle management (RCM), a healthcare organization's financial circulatory system, is comprised of both administrative and clinical functions that contribute to charge capture, management and collection of patient services revenue1. It is the basic process of the organization securing reimbursement for products and services rendered to their patients.

Healthcare revenue cycle has been undergoing a transformation unlike any ever experienced or anticipated in previous eras. This change has effected payers, providers and patient’s alike adding new meaning to “pay for performance” and “patient consumerism,” with defined wellness goals required for care providers and the application of a shared-risk model that has impacted the patient financial responsibility as well as insurers and providers. Never has the healthcare industry been targeted for such drastic change requirements. The expectations are mandating investment and development in new technology to support these adaptations and a demand for a more patient-centric approach to the delivery of healthcare. These two unique initiatives, payment reform and patient consumerism, have spear-headed the RCM transformation and have impacted the industry in a manner that allows patients, for perhaps the first time in history, to be actively involved with their wellness, care choices and healthcare financial planning, making the evolution of technology, methodology, application and patient satisfaction necessary to a successful adaption and adoption.

In 2015 the HIMSS Revenue Cycle Management Task Force created an infographic depicting their vision for the Patient Financial Experience of the Future which highlighted current patient choices for healthcare needs, necessary awareness of impending financial obligations based on insurance coverage, their expected patient contribution, and what financing and payment options, including the utilization of Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) and other alternate healthcare self-funding options that may be available to them. Moreover, the infographic displayed a demand for the healthcare industry to react much like a retail setting providing offerings and technological options to support convenience, transparency and ease of use for the consumer. Patients now want to use their personal devices to schedule appointments, research treatment options, get estimates, and arrange payment plans, finance care and other related health and wellness tasks. Patients want to complete their information one time and not requested to duplicate these efforts at every point within the care continuum. Equally important, they want their providers to share their information and connect with them in their preferred method of communication whether that be a text, phone call, email or portals positioning the business of healthcare to replicate other consumer experiences. Patients want convenient, secure, affordable, technologically advanced healthcare.


Transitioning the healthcare continuum to a more patient-focused, retail-like environment is not without patient responsibilities. Patients are being asked to take a more active role in maintaining their health. They must assume maintenance of their personal medical records, utilizing portals to share and disseminate their health information to care providers as well as assuming more of a shared financial burden for their care. This added financial liability has led organizations like HIMSS and its RCI Task Force to undertake the creation of a roadmap for an improved patient financial experience of the future. Patient satisfaction and the future of healthcare revenue cycle management is contingent upon making these changes a reality.

OVERVIEW

The HIMSS RCI task force embarked on the task of identifying gaps in the patient financial experience while engaged with a specific segment of the healthcare delivery system. This group was comprised of revenue cycle consultants, vendors, payers, providers, financiers, HIE’s, representatives from HFMA, AMA, The Advisory Group, academic medical centers and various other contributing organizations all focused on a common goal, dissecting the current state environment within hospital encounters to improve the patient financial experience of the future.

The HIMSS RCI Task Force began work in 2011, focusing efforts on addressing the patient financial experience as it related to the patient’s overall satisfaction when immersed in the U.S. healthcare delivery system. Throughout the past several years, this topic has garnered attention from diverse industry experts volunteering their time and efforts to contribute their thoughts, ideas, skills, technical knowledge and personal and professional experiences to create a shared vision for improving the patient financial experience of the future. This vision was finalized in 2014. After socializing their vision through a white paper titled Rethinking Revenue Cycle Management, a microsite portraying a patient’s journey, and the 2014 HIMSS Annual Conference listening session, the group turned its attention to encouraging the industry to realize this vision. In 2015, the task force completed the first in a series of five gap analyses, each aimed at identifying the technological functionality required for specific participants within an episode of care to facilitate the task force’s vision of the Patient Financial Experience of the Future. The initial analysis focused on functionality required to support patient-facing activities, a subsequent paper spoke to the functionality required for primary care physicians supporting patient-facing activities and this paper will define functionality hospitals will need to support the vision. Future papers will concentrate on the functional components required for post-acute care facilities, and finally, payers to complete the gap analysis series.


The Patient Financial Experience of the Future is a goal for the present.


http://www.himss.org/library/health-business-solutions/rethinking-revenue-cycle-management

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjL8aTn0sjSAhVOxmMKHVHpAtgQjRwIBw&url=https://www.youtube.com/watch?v%3D65rWHgIc8jM&psig=AFQjCNGB4khDGtpRXX52tlkKgaF2FP94nA&ust=1489122201306292

This hospital gap analysis paper, like its predecessors, is intended to be a living document. It will evolve as solutions designed to fill these gaps are identified, developed and adopted through the continued work of the task force’s analysis and as new revenue cycle processes emerge in the ever-changing business of healthcare today.

GUIDING PRINCIPLES

All work products delivered by the HIMSS RCI Task Force demonstrate adherence to a specific set of guiding principles. Solutions promoted by the task force must:

• be patient-focused;• support transparency of information;• reflect process driven, non-duplicative business practices;• leverage existing and emerging technologies;• demonstrate a sustainable return on investment;• have standards-based architectures;• be intuitive and include simplified user interfaces; and• be designed with the full revenue cycle business process flow in mind.

In 2017, the RCI task force applied these principles to identifying technical functionality gaps within a hospital setting. Gaps in treatment plan options, financial estimates, pricing transparency and technological solutions mandate the industry’s awareness and attention to realize the task force’s vision of executing the Patient Financial Experience of the Future.

APPROACH TO GAP ANALYSIS

Those of you familiar with our previous papers, which focused on the patient and the provider, will notice some similarities between documents. . Although the hospital gap analysis replicates recommendations made in earlier work, the paper also highlights technological solutions that were not discussed in the previously. Solutions include the ability to provide accurate patient estimates for both hospital care and the supporting continuum of care as specifically recognized in pre-care and post-acute care activities.


Undertaking a project of this magnitude and scope requires engagement of stakeholders from every area of healthcare, and their supporting organizations. Many of the team members have extensive knowledge and experience in hospital and physician practice revenue cycle management, a bonus when outlining current state processes, while others are more heavily involved in retail, finance and technology. The background differences in the group afford a diverse and well-rounded approach to envisioning the technical functionality for future state success. Premier health care institutions are well represented with Kaiser Permanente, Mayo Clinic and Johns Hopkins Medicine volunteering their time and resources to the cause, as have smaller consulting firms, financial institutions, cyber security and mobile technology companies. Clinicians and administrators complete the cross-functional group; all actively participating in a cause where shaping the Patient Financial Experience of the Future is a goal for the present.

Task force members are asked to suspend everything they believe to be true about what can or cannot be done as part of the revenue cycle process. The Patient Financial Experience of the Future must be viewed first through the eyes of the patient. With that vision crystalized in their minds, the task force members’ next step is to think in terms of “what if” to identify the technology required to realize the vision. If healthcare services could be effectively priced in advance of receiving care, what technical functionality would be required to provide that information to the patient? What technical functionality would be required to facilitate real-time information exchange between payers, providers, and financial institutions?

To complete its analysis, the task force began with the same basic framework used to conduct the patient perspective gap analysis discussed in Part I of this series. The task force examined each step of the patient’s journey, including pre-care activities, treatment, coordination of care, and patient satisfaction, considering specific activities involved in each of the steps as envisioned in the Patient Financial Experience of the Future. The group reviewed the technical functionality required to support these activities from the providers’ perspective, and identified potential gaps between the functionality that exists today and the functionality that will need to be developed to fully realize the task force’s vision. The following is an overview of the task force’s findings.



HIMSS would like to thank the following authors for their contributions to this white paper:

Maureen Clancy, MBA, FACHE, CPCSVP, Revenue Cycle ManagementPrivia Health

Lisa Tonkinson, CMRPSenior Consultant Revenue Cycle, Supply Chain, Pharmacy & Technologye4 Services

Sandra Wolfskill, FHFMADirector, Healthcare Finance Policy/Revenue Cycle MAPHealthcare Finance Management Association (HFMA)


Gap... · Web viewThroughout the past several years, this topic has garnered attention from diverse...

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Transcript of Gap... · Web viewThroughout the past several years, this topic has garnered attention from diverse...