REVENUE CYCLE STRATEGIST

Insights and actions for successful results REVENUE CYCLE STRATEGIST February 2017 hfma.org/rcs Using Palm Vein Technology to Accurately Identify Patients By Lola Butcher BayCare Health uses palm vein technology to identify patients quickly and accurately, streamline patient check-in, eliminate medical-record mix-ups, and improve patient safety. Revenue Cycle Processes How Carolinas HealthCare System Improved Transparency and Curbed Denials 4 Patient Payments 3 Ways to Transform Pre- and Point-ofService Patient Payments 7 Figure at a Glance Consumers Have Less Credit Available to Fund Their Care 8 Sponsored by www.parallon.com

technology Using Palm Vein Technology to Accurately Identify Patients By Lola Butcher If a person gives five different names over a five-month period, we are still able to get the correct patient medical record to the treating provider, regardless of the patient s name, says Kandy Swanson, BayCare Health System. Daniel R. Verdon Vice President, Publications and Digital Assets Betty Hintch Senior Editor Linda Chandler Production Specialist Revenue Cycle Strategist is published 10 times a year by the Healthcare Financial Management Association, Three Westbrook Corporate Center, Suite 600, Westchester, IL 60154-5732. Presorted nonprofit postage paid in Chicago, IL 60607. 2017 Healthcare Financial Management Association. Volume 14, Number 1 Subscriptions are $130 for HFMA members and $175 for other individuals and organizations. Subscribe online at www.hfma.org/rcs or call 800-252-HFMA, ext 2. To order reprints, call 800-252-HFMA, ext. 384. To submit an article, contact Betty Hintch at bhintch@hfma.org. Material published in Revenue Cycle Strategist is provided solely for the information and education of its readers. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions in Revenue Cycle Strategist articles and columns are those of the authors and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear in such articles or columns do not constitute endorsements by HFMA. MORE ONLINE Subscribers can access back issues at hfma.org/rcs. ISSN 1549-0858 When patients present for care at BayCare Health System, a 14-hospital system serving Tampa and central Florida, they rest a hand briefly on a scanner that detects the unique vein patterns on their hands. Those palm vein images are used to identify patients quickly and accurately, streamlining patient check-in, eliminating medical-record mix-ups, and improving patient safety. Using biometric technology for identification is working well for patients, clinicians, and the registration staff, says Kandy Swanson, BayCare s director of admitting and registration. The technology makes use of the fact that people s palm vein structures are much more unique than their fingerprints. Using invisible infrared light, a palm scanner detects blood flowing through patients veins and creates digital signatures that are stored in the health system s computer. If a patient came to one our facilities 15 years ago when she was single, and she comes to another facility today married and with a different name, we are able to link her to all her medical records using the palm vein image, Swanson says. Biometrics to the Rescue Historically, BayCare used patients Social Security numbers as the unique data points for patient identification. In 2008, system leaders started searching for an alternative because they knew patients preferred not to share their Social Security numbers. We were hearing from our patients that they were concerned about identify theft, and patients were quite vocal about not wanting to give out their Social Security numbers, Swanson says. About the same time, BayCare was launching an electronic health record (EHR) system, which allows staff to access patients medical records as soon as they are registered. It s paramount that we have the patient identified correctly so we get the correct medical record to the treating physician as soon as possible, she says. Matching medical records with patients correctly is a challenge for most health systems, in part because they have so many duplicate records. A 2013 study prepared for the Office of the National Coordinator for Health Information Technology reported an analysis of 112 master patient indexes that found a mean duplication rate of 8 percent, while a separate analysis of 11 patient indexes found duplication rates ranging from 7-39 percent. In a presentation at HIMSS16, Raymond Aller, MD, director of informatics at the University of Southern California, said many health systems underestimate the problem of duplicate records. He cited one hospital that found 69,807 cases in which two or more patients shared the same last name, first name, and date of birth. That hospital had records for 2,488 patients named Maria Garcia and 231 of the records had the same date of birth. Another challenge in matching the right record to the right patient reflects the fact that some patients present false identification when they register. For example, uninsured patients may borrow someone s insurance card to gain access to care, and some patients seek care under an assumed 2 February 2017 Revenue Cycle Strategist

identity for various reasons. Biometric technology helps front-desk staff sort those situations out. If a person gives five different names over a five-month period, we are still able to get the correct patient medical record to the treating provider, regardless of the patient s name, Swanson says. That is a huge win because patients are going to get the care they need, regardless of who they say they are. Benefits of Palm Vein Technology Shortly after introducing the palm vein scans, BayCare took the additional step of inserting patient photographs into their medical records. We call it the gold standard of patient identification, Swanson says. In addition to its top benefit the ability to accurately match patient to medical record the biometric patient-id process offers several advantages for the health system. Streamlined registration. We are saving time on every visit because we don t have to ask for a driver s license or a Social Security number and explain why we need that information again even though the patient has been here before, Swanson says. Patient satisfaction. Because front-desk staff no longer ask patients for forms of identification, their concerns about identify theft are alleviated. Moreover, patient photographs offer greater privacy in waiting rooms. Instead of calling out patients names, nurses or technologists who will room patients use the photographs to find patients in waiting rooms. They can go right over to the patient and say, Please come with me, Swanson says. It s more personalized and more private. Early ID for clinicians. Treating clinicians like being able to view the photographs of patients they will be seeing before they enter the exam room. Biometric Technology Implementation BayCare s registration leaders and information services staff worked together to integrate the biometric technology with the EHR and registration systems. The new patient-id process was rolled out to all hospitals, outpatient centers, and ancillary services facilities over a two-month period. In the eight years since the palm vein identification option was introduced, more than 1.2 million patients have enrolled. Before the new process was launched in its facilities, BayCare participated in more than 50 health fairs and other community events to educate patients about its plans to use biometric images. We knew that it would seem very different, Swanson says. We started introducing the concept so people could start talking about it, and when patients came into the healthcare system, they likely would have heard about the new technology out in the public. During those community events, BayCare staff highlighted the following advantages of the new technology for patients. > > Accurate identification, eliminating the possibility that imposters could use patients insurance benefits > > Faster check-in > > Confidence that all BayCare medical records would be merged together and linked to patients palm vein image > > No need to produce ID documents at medical appointments or in the emergency department On patients first visits to BayCare facilities, registration staff ask for legal identification such as driver s licenses or state ID cards. Patients place their hands on scanning devices and, in less than four seconds, palm vein images are recorded and matched to patients identification. We scan that information into our EHR, and forever after, that image will be associated with that patient at the time of registration, Swanson says. It doesn t matter which facility you visit; we will recognize you. Photo ID. About a year after the biometric identification launched, BayCare added photo identification. Each registrar s workstation is equipped with a webcam that allows patient photographs to be taken quickly. Registrars tell patients that photographs are being inserted into their medical records as a patient-safety measure, and patients readily accept it, Swanson says. Kiosk registration. In a subsequent phase of the initiative, BayCare introduced patient registration kiosks in its outpatient facilities, hospitals, and emergency departments. Each kiosk is equipped with palm scanning devices. Patients can quickly register themselves, Swanson says. That has been embraced wholeheartedly by our patients. Improved Patient Identification Patients who are wary of biometric or photo IDs have the option of using their Social Security numbers as their unique identifier, but few choose that. In the eight years since the system was introduced, more than 1.2 million patients have enrolled. There were only a handful of people either at the fairs or when we went live initially that said, No, this is not for me, Swanson says. The use of palm vein technology for patient identification has allowed BayCare to streamline its registration processes, reduce the problems associated with duplicate medical records and medical identity theft, and improve patient safety. Lola Butcher is a freelance writer and editor based in Missouri. (lola@ lolabutcher.com) Interviewed for this article: Kandy Swanson is director of admitting and registration, BayCare Health System, Tampa, Fla. hfma.org/rcs February 2017 3

revenue cycle processes How Carolinas HealthCare System Improved Transparency and Curbed Denials By Laura Ramos Hegwer New processes and automation helped the health system cut denied dollars in half for radiology services alone. Back in 2007, leaders at Carolinas HealthCare System, Charlotte, N.C., wanted to make their pre-service processes more efficient and effective. Specifically, they wanted to reduce denials, improve collections, and help staff work more productively. Yet it was the desire for greater price transparency that helped the project pick up momentum. Price transparency helped us make the case for more automation, says Katie Davis, assistant vice president of corporate patient access and patient financial services for the health system that includes 950 care locations responsible for nearly 12 million patient interactions each year. We had started on the road to automation in patient access, but the push for price transparency put it on everyone else s radar. Since then, their efforts have helped protect valuable patient relationships as well as the bottom line. Specifically, leaders at Carolinas HealthCare System boosted pre-service collections from $3 million in 2014 to $4.6 million in 2015. efficiencies. After a three-month pilot, the health system immediately saw a jump in productivity. However, the pre-service process was still labor intensive, considering staff handled approximately 17,000 preregistrations per month. At that point, leaders recognized they needed to move away from manual processes. We couldn t get any more efficient if we did not automate the processes, Davis says. At the same time, patients and staff were becoming dissatisfied with how the health system provided price estimates. Initially, staff searched payer websites or combed through a large book of pricing codes to provide patients with an estimate for their scheduled service. Later, they tried a free Carolinas HealthCare System Pre-Service Cash Collections Grow pricing tool that was added on to their patient accounting system. Neither strategy worked well. The price estimates were completed by our managed health resources department and sent to the outreach call center to be given to patients, Davis says. However, the call center staff did not understand insurance benefits and could not explain them to patients. As a result, patients did not understand exactly why they owed the estimate. Sometimes, a week would go by before patients heard back from the call center staff with the estimate. Davis was concerned that such problems would have a negative impact on the health system s patient relationships over the long term. To remedy the problem, Davis and her team investigated various price estimators. They also investigated tools that would automate authorizations. After selecting two such tools, they moved forward with the implementations in 2013. Leaders started the rollout at just one facility and focused on radiology services, which are often easier for creating estimates because they tend to have a fixed price. From there, leaders Leaders at Carolinas HealthCare System improved pre-service collections from $3 million in 2014 to $4.6 million in 2015. Automating Pre-Service Processes Until 2007, the pre-service department at Carolinas HealthCare System had manually handled preregistration, insurance verification, prior authorization, and up-front cash collections for all high-dollar scheduled services such as surgery and radiology for 11 facilities. Over time, this had become very labor intensive, Davis says. Staff would work through all four phases of the pre-service process [preregistration, insurance verification, prior authorization, and up-front cash collection] until they were finished with each account. Then in 2007, we divided those tasks among dedicated teams to gain some $3,033,136.68 $3,017,422.47 $2,476,031.56 $2,409,869.92 $2,533,292.15 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: Carolinas HealthCare System. Used with permission. $2,712,431.86 $3,292,701.65 $3,096,344.21 $4,657,798.23 4 February 2017 Revenue Cycle Strategist

Carolinas HealthCare System Denials for Radiology Services Decrease For radiology services alone, Carolinas HealthCare System cut denied accounts by 24.7 percent and denied dollars by 46.7 percent from 2013 to 2014. Denials 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 0 $3,282,947.00 961 Denied Dollars 723 Accounts 2013 Accounts 2014 $1,747,259.00 $3.5 $3.250 $3 $2.75 $2.5 $2.25 $2 $1.75 $1.5 $1.25 $1 $.75 $.5 $.25 $0 Denied Dollars (millions) in tandem with the pricing estimation tool, would free up their time. When we pre-register a patient, we can automatically see the patient s insurance benefits, Davis says. If the benefits are correct, the case will automatically move to authorization. Services can be authorized in total, authorized in part, or returned with no authorization found. Any account problems automatically populate a work queue, enabling staff to focus on the accounts with the highest potential for denial. Otherwise, it is primarily a hands-off process. To jump-start the learning process, the software vendor trained several super users on the authorization and pricing estimation tools. These super users were staff members in the department who were good at training others, Davis says. Then the super users, along with supervisors and managers, trained the staff as we rolled out the tools facility by facility. Realizing Results Leaders at Carolinas HealthCare System quickly realized results from the health Source: Carolinas HealthCare System. Used with permission. expanded the implementation to other facilities in the health system. The tool creates an estimate based on charges, contract rates, and patient benefit information. We can review how much of the patients deductibles have been met, which is important because many patients are moving to high-deductible plans, Davis says. Now, we can give patients a much better idea of what their financial responsibility is. For surgery estimates, staff can give patients the average price based on the previous year s data. We don t give patients a price range, but rather we say it is the average price and that the true price can change depending on several variables, such as time in the operating room and recovery, Davis says. Estimates do not include any physician charges. Making prices more transparent for patients is part of the health system s broader strategy to build better, more meaningful relationships with patients, Davis says. We want to make sure patients understand what their benefits are, she says. So many people think their insurance is supposed to cover everything. We work hard to make sure they understand their financial responsibilities and don t get sticker shock. Training Staff Davis says her team was eager to adopt the new price estimator and other automated revenue cycle processes because leaders promoted the benefits early on. The staff understood that the changes would help them work faster and smarter, Davis says. For example, the team realized that the automated authorization tool, which works explore apply be recognized Apply Now hfma.org/mapawards hfma.org/rcs February 2017 5

system s new capabilities and workflows. In 2013, radiology denials alone totaled slightly more than $3.2 million. In 2014, radiology denials dropped to $1.7 million. They also were able to repurpose staff. Thanks to automation, revenue cycle staff can handle 40,000 preregistrations a month with fewer FTEs than they had in 2007. We only have to touch 20 percent of accounts, instead of 100 percent of accounts, every day, she says. Leaders have moved FTEs to other areas in the corporate patient access department and elsewhere. In addition, the health system s price estimation call line, which is staffed by a two insurance specialists, now reports up through Davis team. We can give patients their estimated financial responsibility when they call us, she says. We get their insurance information, key it in while they are on the phone, and give them an estimate that is just for that particular facility. Looking ahead, leaders plan to evaluate the system for use in the clinics, Davis says. Implementing Improvements Davis provides the following suggestions for leaders who want to decrease denials and make prices more transparent for patients. Research different technologies. You need to do a lot of homework to see what type of solution fits your needs and your situation, Davis says. Giving staff some say in the product selection helps to improve buy in, she adds. It also helps to understand the nature of the technology. Any kind of estimation tool is not plug-and-play software, she says. Don t be wedded to old processes. You have to be open and willing to change what you have been doing, Davis says. Conduct quality checks every quarter. This can help ensure that estimates given to patients are accurate. Focusing on Change Management Ramping up to offer price estimates to patients can be an arduous process, Davis says. You have to spend a lot of time getting it right because those relationships with patients are really important, she says. Leaders also need to be able to lead their team through change, Davis says. For example, training all staff to say estimate instead of quote was just one of the many cultural changes they needed to make at Carolinas HealthCare System. This is a very detailed process, and you have to address those details when you are training, she says. Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill., and a member of HFMA s First Illinois Chapter (laura@ vitalcomgroup.com). Interviewed for this article: Katie Davis is assistant vice president of corporate patient access and patient financial services, Carolinas HealthCare System, Charlotte, N.C. (Katie.davis@carolinashealthcare.org). See the patient-centric revenue cycle in a whole new light. The all-new CRCR from HFMA Make HFMA your staff career development partner. Healthcare rules are becoming more complex. Patients are demanding a better experience. HFMA s new CRCR is the only content available today that provides a national-level certification for addressing the contemporary patient-centric revenue cycle. Take the first step at hfma.org/crcr. 6 February 2017 Revenue Cycle Strategist

patient payments sponsored by Parallon 3 Ways to Transform Pre- and Point-of-Service Patient Payments By Tom Yoesle Although hospitals are starting to make progress, there is more work to be done. When it comes to pre-service and point-ofservice (POS) collections, 2017 is a critical year for healthcare organizations. Hospitals have experienced a 10 percent increase in self-pay dollars in the past five years, according to the report HFMA Executive Survey: Self Pay and The Benefits of Prospective Patient Engagement, which surveyed 117 hospital finance leaders. The report also found that 35 percent of respondents do not offer pre-service or POS collections for inpatient areas, and 25 percent do not have pre-service or POS collections in the emergency department (ED). Yet, healthcare finance executives say POS collections and automation are the top self-pay processes they are most interested in implementing. The report reinforces that providers have significant opportunities to capture additional payments before and at POS. Although hospitals are starting to make progress, there is more work to be done. It s time to map out an innovative game plan that improves pre-service and POS collection strategies. Moreover, in the age of Amazon and retail healthcare clinics, pre-service and POS planning must include new ways to interact with savvy healthcare consumers who expect more from providers, including value-added services. Here are three ways providers can improve pre-service and POS collections while engaging patients and improving the patient experience. Automate pre-service registration and POS collections. Hospitals are looking for new ways to augment pre-service and POS collections. State-of-the art automation processes now enable patients to pay their bills quickly and effortlessly. For example, prior to the inpatient visit, healthcare organizations are emailing patients a link to complete registration forms and to pay out-of-pocket costs. In doing so, they are collecting pre-service online registration data, which can drive automated insurance verification and authorizations. This is the cornerstone of an exception-driven registration process, which aims to be as efficient and patient friendly as possible. Being a good steward of patient experience includes having a streamlined discharge process with an in-person conversation about the billing cycle and handling same-day payments and payment plans. Offer additional patient-friendly services and health system information. Creating positive and efficient ways for patients to pay their bills both pre-service and at POS opens the door to offer additional services to healthcare consumers. Just as Amazon urges its buyers to consider complementary items at the point of sale, hospitals have an opportunity to do the same, including offering the following options. > > Preventive care services, such as mammogram screenings > > Prepaid cafeteria cards > > Gift shop coupons and gift cards > > Crowd funding options to assist with hospital bills In addition, hospitals have an opportunity to tell patients about community benefit information contained in their community health needs assessment, such as collaboration with local public health agencies, free health screenings, and how they monitor community health improvement efforts. Design a strategic ED discharge process. Most hospitals were designed 40 to 50 years ago when throughput was a critical factor. There was little thought about how to discharge patients safely while still collecting insurance information and payments. In fact, today a high percentage of patients still leave the ED without being asked for insurance information. In doing so, hospitals disregard the revenue cycle part of the patient experience and potentially create financial harm when patients are surprised with their first statements 30 days after the visit. Being a good steward of patient experience should include a streamlined discharge process with an in-person conversation about what to expect during the billing cycle and methods for handling same-day payments and payment plans. Healthcare providers can seize opportunities to improve patient payments both at POS and prior to the time services are provided through automation, patient-friendly services, and strategic discharge processes. By making these changes, hospitals and health systems can offer improved payment options that increase patient satisfaction and encourage timely payment. Tom Yoesle is COO, revenue cycle point solutions, Parallon, and a member of HFMA s Florida Chapter (tom.yoesle@ parallon.com). hfma.org/rcs February 2017 7

PRESORTED NONPROFIT U.S. POSTAGE PAID PERMIT NO. 73 PALATINE, IL Three Westbrook Corporate Center Suite 600 Westchester, IL 60154 To subscribe, call 800-252-HFMA, ext. 2, or visit hfma.org/rcs Sponsored by www.parallon.com figure at a glance Consumers Have Less Credit Available to Fund Their Care Consumers available revolving credit to pay healthcare costs declined in the first quarter of 2015 from $2,250 for every $100 in medical costs to $1,720 in the first quarter of 2016, according to an analysis by TransUnion Healthcare. Patients in the subprime risk tier, generally the highest-risk consumers, also experienced a decline in available credit over a one-year period. As of the first quarter of 2016, these patients only had $420 in revolving credit for every $100 in healthcare costs, compared with $600 a year earlier. Consumer Revolving Credit Line Amounts, Q1 2014 Q1 2016 For every $100 in healthcare costs, consumers had the following revolving credit to potentially make those payments. Consumers/Year Q1 2014 Q1 2015 Q1 2016 All consumers $2,310 $2,250 $1,720 Subprime consumers $660 $600 $420 Source: TransUnion Healtcare. Used with permission.