1.2 Healthcare Dollars and Sense Questions and Answers 2023

1.2 Healthcare Dollars and Sense Questions and Answers 2023 What are the 3 HFMA initiative in Healthcare Dollars and Sense (HD&S)? Purpose of HD&S? Method of HD&S? What is HFMA's adopter program? (1) Price transparency (2) Patient financial communication/discussion (PFC/PFD) best practices (3) Medical account resolution (back end) PURPOSE: aims to make sense of price and value in healthcare (because patients, consumers, employers, insurers, and public officials want to understand and get the best value for their dollar) METHOD: the initiatives combine recommendations from stakeholders across healthcare (hospitals, physicians, insurers, consumers, public officials, employers, and credit agencies) to improve the way we communicate about healthcare prices HFMA's adopter program: Providers who implement and support these best practices can apply for recognition by HFMA as an Adopter of the PFC Best Practices What is the goal of the Patient Financial Communication (PFC) best practices? What are the best practices sections? GOAL: Provide consistency, clarity, and transparency. PFC: definitive guidance about topics and parameters of discussions Best practices sections: where best practices are most urgently needed to provide definitive guidance about topics and parameters of discussions, also known as PFC. SECTIONS: -All (??) -Emergency Dept (ED) -Advance of Service (AOS) -TOS (excluding ED) -Measurement Criteria Framework: guides evaluation of an organization's voluntary compliance What are the guidelines for WHEN and WHERE to have PFC in the following environments: TOS (ED) TOS (Outside ED) AOS TOS (Emergency Department - ED) -PFDs must occur after patient is screened and stabilized in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA) and other fed/state/local regulations governing the ED -Screened -- Emergency Medical Condition: discussion occurs during the discharge process -Screened -- Not Emergency Medical Condition: discussion may occur in registration or discharge process TOS (Outside ED) -Discussion takes place during registration or discharge provided the location does not disrupt patient flow -Across all settings, if a patient consents to financial discussion during a medical encounter to expedite discharge, the best practices support that choice provided that the discussion does not disrupt patient care or flow AOS (Advance of Service) -Use the most appropriate means of communication for the patient, whether outbound via contact to patient, inbound via patient inquiry, or through CS/contact center at the time the appointment is made. -Timeliness: make a reasonable attempt to have the discussion as early as possible before a financial obligation is incurred. This (a) Ensures the patient understands their financial obligation and (b) Ensures that providers are aware of patient's ability to pay and/or payment source What are routine and complex scenarios for the PFC? What assistance is available? Assistance: health coverage is complicated, and patients should be given the opportunity to request a patient advocate, family member, or other designee to help in discussions Routine Scenario: -Patient has insurance coverage or known ability to pay -Financial discussions take place between patient or guarantor (person responsible for bill payment) and the trained provider representatives Complex Scenario: -Uninsured or underinsured patients -Financial supervisor should be involved What are routine activities that should be part of PFC? Provision of Care: Ability to pay will not interfere with treatment of emergency medical conditions (see more on next flashcard). Registration: No patient financial discussions can occur before ED screening and stabilization. Once a patient is stabilized, gather registration info (demographics and insurance coverage) and determine need for financial assistance. Insurance Verification: review insurance eligibility information with the patient to ensure accurate information. Financial Counseling: Publicize a toll-free number to receive assistance in financial matters. Refer the patient to financial counselor or give the patient info re: financial counseling services and assistance policies. In AOS, provider should maintain list of preregistration discussions and avoid repeated questions. (see more on following flashcard). How is Provision of Care addressed during PFC? -Ability to pay will not interfere with treatment of emergency medical conditions -Tell uninsured ED patients that the goal of collecting info is to ID paying solutions or financial assistance options to aid with financial obligations of ED visit -Affordable Care Act marketplace and Medicaid expansion -- important for hospitals to help patients understand coverage options -Publicize clear policies on how to interact with patients with prior balances across all hospital settings -Publicize clear definitions of elective and non-elective procedures (defined by provider): (a) Non-elective services: patients' ability to resolve any prior balances or current services will not affect provision of care (b) Elective services: patients are obligated to make satisfactory payment arrangements prior to receiving service whether payment in full or mutually acceptable payment arrangements. Provider policy may specify that services will be deferred for a patient with prior balances. What are the components of financial counseling in PFC? Financial Counseling: patient share, prior balances, and balance resolution. Definition (repeated from above): Publicize a toll-free number to receive assistance in financial matters. Refer the patient to financial counselor or give the patient info re: financial counseling services and assistance policies. In AOS, provider should maintain list of preregistration discussions and avoid repeated questions. Patient Share: -Inform patient of types of service providers involved in their service (e.g. radiologists, pathologists, etc.) and offer a written list at request -Inform patient that actual cost may vary from estimates depending on actual services performed or timing issues related to other payments that may affect their deductible -Patients must be asked if they want info about receiving info about payment options and/or provider's financial assistance options -PFCs should not interfere with patient care and should focus on education Prior Balances: -Providers must publicize clear policies about prior balances -Providers must have tech that give financial reps current info about patient balances and financial info Balance Resolution: -PFCs should focus on steps towards amicable resolution -Balances may be with provider, collection agency, or other organization -Provider, at request, should provide service list, dates, and resulting balance -Provider may offer financial assistance programs or proactively resolve the balance through insurance and financial assistance programs What are the Provider Patient Convo best practices for PFC? Compassion: Patients are vulnerable so clear, early PFCs give patients peace of mind Communication: Initiate and take this burden off the patient. Confirm contact info. -Standard Language: employ standard language taking into account patient's perspective Written Follow-up: reinforce verbal info with written info -Provide this info during registration or discharge process -Make this info available to the community -Give this info in a location and manner sensitive to the patient's needs Compliance Framework: -Training Program: require annual training on financial assistance policies for all who engage in PFCs including PA, financial counseling, and customer service reps. Can be online or in-person, internal or external (as designated by quality officer). Topics: PFC best practices specific to staff role, financial assistance policies, available patient financing options, alternative solutions for the uninsured, standard language, and laws and regs (EMTALA, Fair Debt Collections Practice Act, Telephone Consumer Protection Act) specific to role -Process Compliance: comprehensive annual observation, monitoring, and tracking of results performed by an organization independent of audited organization (compliance, quality, internal audit, or third party), should cover all scenarios addressed by practices that are relevant to the org -Executive-level metrics reporting: Reports of performance evaluations in the four sections (Training, Compliance, Tech, and Feedback), should be compiled into an overall compliance report and presented to provider execs annually -Tech: tech must support verification of insurance eligibility for current services, verification of existing prior balance for current services, and estimated cost of the current services and the patient responsibility portion. Tech eval can be performed by any internal or external qualified individual or organization -Feedback process and response: Evaluate that the provider has processes to obtain input and receive key stakeholder's feedback. Providers must measure and respond to input and ensure complaint resolution. HFMA's adopter program: Providers who implement and support these best practices can apply for recognition by HFMA as an Adopter of the PFC Best Practices What's the actionable definition of Price Transparency? What is the pricing transparency process? Actionable definition: "Readily available information on the price of health care services, that, together with other information, helps define the value of those services and enables patients and other care purchasers to (1) identify, (2) compare, and (3) choose providers that offer the desired level of value." -Created by the HFMA Task Force, who developed Price Transparency Report and Consumer Guide to Healthcare documents, clarified definitions, set forth guiding principles and recommendations for price transparency that allow hospitals, physicians, and health plans can share reliable info on prices with consumers. Combined this info with quality and safety info. Pricing Transparency Process: Taking the service charge based on CPT or MS-DRG code and applying a hospital payer's contract terms and the patient's benefit plan to determine an accurate patient liability 1. The patient calls the hospital priceline to inquire about potential fees and costs 2. Patient provides the physician order (e.g. cervical spine MRI) and insurance info 3. Representative electronically verifies the insurance and the pricing software develops a patient-friendly estimate form of patient liability: what the patient is responsible for How did the Affordable Care Act (ACA) contribute to Price Transparency? What trends contributed to Price Transparency? The Affordable Care Act legislated the development of a Health Insurance Marketplace aka Health Insurance Exchange where individuals and small businesses can compare and purchase qualified health benefit plans Many of the plans have a consumer cost-sharing requirement (high deductibles and coinsurance) -Coinsurance is the % after deductible that insurance does not cover and for which patient is responsible -Copayment is the flat amount the patient pays at the time of service -Deductible is the flat amount the patient pays before an insurance plan begins to pay benefits. Copayments factor in here. As consumers take on higher responsibility for the cost of their care, they expect clarity about costs. Transparent pricing has never been more important for patients to make sound decisions about care. -Driven by healthcare provisions that include significant patient liability portions -Driven by consumer-driven provisions like health savings accounts (HSAs) and health reimbursement arrangements Consumers compare plans and later providers by looking for info about high-deductible plans and the impact of various co-insurance amounts on their individual financial responsibility.