Patient Liability Estimators
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Patient Liability Estimators: Side by Side Comparison Katie Harwood, CHAM Patient Access Services Manager, Financial Advocates
Transcript of Patient Liability Estimators
Patient Liability Estimators:
Side by Side Comparison
Katie Harwood, CHAM
Patient Access Services Manager, Financial Advocates
University of Utah Health Care:
4 Hospitals, 10 Neighborhood Health Centers,
200 Medical Specialties, 1,000 Board-Certified Physicians
for LEVEL I TRAUMA
The University Hospital Emergency Department
Intensive Care | Burn Center | AirMed
for HEART CONDITIONS AND DISEASES
The Cardiovascular Center
for WOMEN’S HEALTH
Women’s Health Services
Level III Newborn Intensive Care Unit
for SOLID ORGAN TRANSPLANTS
The Transplant Center
for CANCER CARE
The Huntsman Cancer Hospital
for PRIMARY CARE
The Neighborhood Health Centers
for EYE CARE
The John A.Moran Eye Center
for PHYSICAL REHABILITATION
The Rehabilitation Center
for ORTHOPEDIC CARE
The University Orthopaedic Center
for NEUROLOGICAL DISORDERS
The Clinical Neurosciences Center
for BEHAVIORAL AND MENTAL HEALTH CARE
The University Neuropsychiatric Institute
We Provide: Comprehensive Care in the Intermountain West
Serves the largest catchment area of
any academic medical center in the country,
with a referral area that encompasses
more than 10 percent of the continental U.S.
Ensures that patients from Utah
and five surrounding states have access to the
best, most specialized care.
Provides services available nowhere else
in the region, such as University Hospital’s
Burn Center and the Moran Eye Center.
As the
Only Academic Medical Center
in the Intermountain Region,
University of Utah Health Care:
Our Mission
We provide compassionate
care without compromise.
We educate scientists and health
care professionals
for the future.
We engage in research to advance
knowledge
and well-being.
Clinical Care | Education | Research
Who We Serve
Over 1 million outpatient visits 30,000 Inpatient Admissions 25,000 Surgeries
About UUHC
Our current EMR is Epic Care for Outpatient and Powerchart Inpatient
Epic for Business was implemented in October 2010
Epic 2012 Upgrade occurred in May 2013
Project Price Estimator
We have an internally developed Estimator in use since May 2010
We call it the Patient Liability Estimator – PLE
• It incorporates our price file and the major contracts.
• Benefits are used to calculate the patient responsibility.
Cash results: Collected $6,374,250 FY13
Scheduling structure
Visits are scheduled in Epic or in separate scheduling systems for Radiology or Surgery visits
Decentralized account creation is done in Epic by Patient Access Staff
Once account is created, it qualifies for the Epic work flows
• Self Pay
• Insured
The Who
We have two
authorization teams
responsible for inpatient
and out patient
scheduled procedures
13 inpatient
23 outpatient
Excludes clinic visits
8 Inpatient Financial
advocate team
5 Pre service hospital
based financial
advocates
6 outpatient financial
advocates for high dollar
procedures done in the
community clinic setting
Work flow ~ Scheduled Admissions
Benefits and authorization team update Epic Patient Responsibility field with amounts to collect for scheduled admissions, inpatient and high dollar outpatient
There are Epic work queues to route the account to the Financial Advocate team
Financial Advocate secures payment from patient prior to service or
Admissions staff completes transaction at the point of check in.
• We collect for the facility, Professional, and Anesthesia
Self Pay
Financial advocates will create the price estimate for self pay- not limited to
• Radiology
• GI
• Scheduled Surgeries
• Scheduled Admissions
Scheduled services considered elective require a minimum prepayment
of 50%
Financial advocates are the Gate Keeper for scheduled admissions – The
Buck stops Here!
Patient Responsibility Screen in Epic
Amount to Collect Displays on the Interactive Face Sheet
Drawbacks
Accuracy of price estimates
• System limitations
• User errors
• Tool Maintenance
Add on- one more program for staff to log into
Did not include Professional Fee Schedule
• Had a secondary estimator for the Professional implemented
in 2012- MPV Patient Responsibility Pricer
Now there are two tools for the team to use
Price estimate comparison
We were motivated to improve our estimate capability when we found out that it was available in the Epic 2010 and 2012 version
We wanted all points of access to have the ability to provide price estimate and copay information
A group was formed to Compare functionality of Price Estimate tools in fall 2012
• Epic
• MPV~Experian
• Clear Quote
What were we looking for?
Combine PB &HB Estimates
Use 271 payer responses
Generate Patient letters with estimate quote
Adjust quotes to include pricing changes
Store quotes for price shoppers to use at a later time
Ability to look at entire case vs. only the CPT
Ability to accommodate multiple fee schedules
Model contract terms
Audit Performance of the price estimates against actual
Considering our Options
Clear Quote Pros Proven product, Industry leader
Ability to look at an entire case, not just
the CPT code
Ability to combine a complete estimate
for both PB and HB, generate combined
estimate letter
Price estimate for shoppers can be
retrieved at a later time.
Ability to pull in 271 payer responses
Ability to calculate discounts-
contribution to care
Uses more than historical information to
be more accurate
Ability to adjust to price increases and
new pricing
Cons
Cost
Bolt on to Epic
Implementation – our ITS resources
are limited
MPV
Pros
No cost to implement
Ability to look at an entire case
Ability to combine a complete estimate
for both PB and HB
Generate combined estimate letters to
Patients
PB is already built in MPV
Existing contract in place, would need
to be amended for HB
Cons Requires users to go outside of Epic –
Bolt on
HB functionality is very new so it may require a lot of development. May be may be hard to find a hospital that we can call on for help
Will need to build the HB contracts in MPV
Cost to build HB in the tool
Monthly Cost
Poor performance from customer service
Epic Pros
No cost to implement(cost to MPV for early termination of contract)
Integrated with EFB
For visits scheduled in Cadence the estimates are automated
Ability to look at an entire case, not just the CPT code
Ability to combine a complete estimate for PB and HB
Generate combined estimate letter to patients
Store price estimates for “shoppers” which can be retrieved later
Ability to pull in 271 payer responses
Ability to support ABN process
Minimal training
HB Contracts are built in Epic
Able to provide copay information at the point of scheduling
Cons Because this functionality is so new we
may face problems the Epic does not have
a solution for. No hospitals to call for help
Estimates don’t use price discounts
There is not a capability to create
“package” estimate such as for full
maternity delivery
Decision made to go with Epic
In the end, we decided to go with the product
that would integrate with our existing enterprise
billing system and long term plan to implement
the full suite of Epic products
• *Project OneChart May 2014*
Where are we today
Project was placed on hold until Epic upgrade to version 2012 in May 2013
Testing and validation
PB contracts interface from MPV
Benefit Collection build
Price file build
Epic Estimate activity and Benefit collection forms
Benefit Collections form
• Can receive automated eligibility responses or
• Manually input Benefit information by service type
Outpatient benefits
Emergency benefits
Hospital Inpatient
Pre-Payment due section
• Information from the benefits fields drive the population of this form,
adding ease for collection
Ability to print an estimate letter
OHSU Healthcare
OHSU Patient Liability Estimator
EPIC Revenue Cycle Western User Group
August 2013
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About OHSU
• Academic Medical Center w/schools of Medicine, Nursing,
and Dentistry with 4,361 students
• One of two Level 1 Trauma centers in Oregon
• Total visits 849,581 Admissions: 29,797 ED Visits: 46,399
Day patients: 26,830 Ambulatory Visits: 735,279
Observation: 4,477 **Total Annual Patients: 235,801
• 48% of our patients are from outside tri-county area
• Largest employer in the state, with over 14,000 employees
• Employ more than 1,000 physicians & 450 Allied
Professionals
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About OHSU
• Our EMR is EPIC (on version 2012 since May)
• Started with EPIC Ambulatory August 2005,
implemented Prelude, Cadence, Resolute Professional
billing and EpicCare
• Implemented inpatient EPIC in April of 2008
(HIM, Resolute HB, ADT, ASAP)
• Optime/Anesthesia January 2012
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Front End Financial Clearance structure
Outpatient
• Decentralized Scheduling
• Centralized registration call center and front end patient
financial assistance application processing
• Partially centralized referral intake & authorizations for
outpatient and inpatient services
• Decentralized patient financial counseling in some areas
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Front End Financial Clearance structure
Inpatient/Day Patient/ED
• Scheduled IP/Day Patient pre-authorizations
decentralized to practices
• Centralized reservations/pre-registration/admitting
• Centralized Insurance Verification Unit for pre-auth of
urgent/emergent IP/Day Patient services
• Centralized Financial & Medicaid Specialists
• (New) Centralized Patient Estimator creation and
delivery to patients
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About OHSU
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Why an estimator?
Drivers for change:
• Increased patient pay balances
• Pre-Service POS Collections - 3 year Initiative
• Inconsistent, fragmented process created a poor patient
experience
• Limited use of Patient Estimator Physician Practices only
• Manually created “Best Guestimate”
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POS Collections Project Goals
• Purchase a price estimator that would incorporate
hospital, professional, and anesthesia charges into one
estimate
• Re-engineer our POS processes to a single point of
communication to convey payment expectations &
collect payment
• Improve the patient experience
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Integrated Project Structure
Established work groups
1. Estimator RFP evaluations & selection panel
(POS Process redesign group)
2. Steering committee - high level stakeholders
3. Process redesign work group
4. Estimator technical team
a. IT – ADT Interface & file transfer
b. HB, PB, Anesthesia Charge file creation
c. HB & PB Contracts
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Estimator Selection
• Required- One estimate that includes hospital,
professional, and anesthesia charges
• Price matters- Same product, different prices
• FHS Clear Quote/Transunion selected
• Patient estimate considers: benefits, median charges,
contracts, provider variance
• Clear Code Auto Add Feature
• Why not use EPIC estimator?
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Patient Estimator
• Can create “shopper” estimates
• Accommodates prompt pay/self pay OR charity care
discounts
• Limited scripting embedded in tool
• Dictionary of healthcare terms
• Common procedure groups
• Work lists – estimates pre-created
• Payment reason codes/amount collected
• Reporting
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Patient Estimator Build
• Contracted payers were notified
• Loaded all hospital and professional contracts
• Built fee schedules as necessary
• All payer/plan records in EPIC are mapped to a contract
or to “No contract”
• Two years worth of charge data, automated a monthly
refresh
• Built HL7 ADT out interface with patient data
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Patient Estimator Build
HL7 ADT out interface:
1. Patient demographics
2. Patient benefits documented in EPIC from a 270-271
query. (Can manually enter in estimate)
3. Payer/plan maps to contract/contract allowance
4. Can include the procedure (ours doesn’t at this time)
5. Populates a work list (contact driven)
6. No ADT “in” interface to EPIC at this time
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Patient Estimate Creation
• CQ System auto creates estimates for all contacts
crossing the interface
• Use CSN to identify and pull up a specific contact
• Patient Demographics, Insurance & benefits, provider,
and type of estimate pre-populated
• User selects primary CPT & selects auto add
• Accept/reject suggested codes/add add’l CPT’s
• Letter created in PDF format & mailed from Outlook
8/13/2013
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Patient Estimator – Lessons learned
• ICD-9 vs. CPT Procedure coding
• Budget increase for 270-271 if using an eligibility vendor
• Add professional groups reimbursed at different levels
ex: Nurse midwives
• Contract alignment – may need to run separate
estimates in some cases
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Estimator Build – Lessons learned
• Two years of charge data – not one – to increase related
visit count
• Reduced “auto add” threshold for adding to the primary
CPT code
• Reduced visit count threshold to be considered sufficient
to create an estimate
• Mark contracts as “evergreen” instead of loading end
dates
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Patient Estimator – Lessons learned
• “Copy” of 271 from eligibility vendor to CQ
• Benefits missing for direct connect and Availity 270-271
• Redirection of 270-271 direct connect interface
• Benefits in Estimate – Validation still important
• Alignment of patient charges in estimator
(Duplicate or missing Anesthesia)
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Process Redesign
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Process Redesign
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Process Redesign
Single point of communication
• Who will create the estimate and tell the patient?
• How much will the patient need to pay?
• Do we schedule before or after patient pays?
• What if the patient can’t meet payment expectations?
• How and where will we document payment
expectations?
• Will we cancel or reschedule if patient doesn’t pay?
• Who gets the money if the patient cannot pay the full
amount?
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Process Redesign
Operational Criteria
• Estimator/Interface are date driven
• Reschedules & Cancelations
• Account available to post payment
• Account available for documentation
• Facilitate Pre-Auth and benefit processing
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Process Redesign
Patient Experience Criteria
• Achieve standardization of patient experience
• My health vs. your money
• Ability to view estimate at time of explanation
• Pay at time of estimate (one stop shopping)
• Smooth Billing Experience
• Ability to respond to patient questions
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Process Redesign Challenges
• Interface or work list trigger
• How to post pre-service collections and document
payment plans with no account number?
• Must have a HAR
• Selecting planned procedure code - accuracy of
estimate depends on it!
• Common documentation
• Reporting on estimates and money collected
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Process Redesign Challenges
Use of referral module status codes:
• Estimate Ready
• Estimate in Progress
• Estimate Not Needed
• Estimate Complete
• Phoned Patient
Use of referral module for documentation of procedure
codes
Note: Planned shift to Huron (On Trac) work list
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EPIC ADT- Money Due Form
Common Documentation
• Copy of estimate in Auth Cert Notes
• Creation of EPIC ADT Money Due form for collection
during admissions process
• Creation of three new payment codes for pre-service
collections during estimate discussion
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EPIC ADT- Money Due Form
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Estimator Pilot – Where are we now?
• Initial Scope includes singly insured patients with
planned, elective admissions and Obstetrics
• All ENT, Neurosurgery, Bariatric, Obstetrics, and 2
Plastic Surgery providers
• Estimates are created by Insurance Verification Unit
• Patients are called by billing customer service staff.
• Minimum of $500 requested
• Need to validate accuracy of estimates (ongoing!!)
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