On the road to consumer-driven health care - Patient Financial Services

Healthcare Financial Management,  Sept, 2003  by Bobette M. Gustafson

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What will it mean for your patient financial services (PFS) department when patients start making their own decisions regarding their coverage? What advice will your PFS professionals have for a patient who is confused about his or her coverage options? How will PFS staff respond to a patient's probing questions about the health plan's adjudication and payment of his or her bill?

As employers increasingly shift the responsibility for coverage decisions to their employees, such questions will become the order of the day for revenue-cycle leaders.

Today's slow economy and soft labor market have compounded employers' struggle with ongoing, staggering increases in health insurance costs. Health insurance is the single largest component of expense growth in many employers' budgets. The 2002 Eighth Annual Washington Business Group on Health/Watson Wyatt Healthcare Survey projected that at the current rate of increase, employers will face the bleak prospect of another doubling of healthcare benefit costs by 2007. Surveying nearly 300 companies that provide benefits for more than 10 million employees, Watson Wyatt reported that 57 percent of respondents confirmed that they were making plans to increase "consumerism" in their next year's benefit plans.

The transition to consumerism goes beyond the trend of increasing patient out-of-pocket expenses. In the new model, the employer reduces its costs and administrative burdens by transferring more control and risk to its employees. The employees become directly engaged in purchasing their coverage, selecting providers, and managing their costs and utilization. This trend, commonly called consumer-driven health care, requires PFS professionals to identify and implement revenue-cycle changes to meet the demands of consumer-driven health plans (CDHPs) or defined-contribution plans.

Revenue-Cycle Implications of CDHPs

Revenue-cycle leaders should expect that, even though consumers will have access to extensive on-line information to help them select benefits, many consumers will look to the provider's PFS staff for clarification and guidance. Therefore, the PFS department should have policies, processes, and a training program in place to help team members respond to the inquiries of these potential customers. The quality of a PFS representative's customer service in addressing such questions may make the difference between a consumer's selecting your facility or another provider's for future healthcare services.

To best respond to the needs and expectations of a service-seeking CDH P member, you must first be able to ascertain whether the individual is a member of a CDHP. Therefore, when verifying the individual's insurance, your PFS staff will need to ask the specific questions necessary to identify such a plan member. This information then should be recorded in the patient profile so that it will be readily accessible, complete, and apparent to all PFS staff members who have interactions with the patient.

As consumers begin to "shop" for providers, revenue-cycle staff will need to respond promptly and knowledgeably to consumers' requests for pricing and cost information that will facilitate provider service and cost comparisons. Many employers and health plans are alreadyy introducing customer-service and technology enhancements to promote the CDHP model and help employee-members select providers and services. They are providing simpler means for plan members to access information quickly and to easily make "plain-English" web inquiries. Health plans are also abandoning frustrating voice-mail systems and providing members with access to 24-hour call centers operated by well-trained, customer-savvy employees.

Consumers will come to expect providers to deliver the same options and level of customer service they are receiving from their health plans. Having become accustomed to around-the-clock "shopping" and health plan access, they no longer will tolerate PFS departments that limit access to PFS representatives to traditional business hours and rely heavily on impersonal voice-mail processing. PFS departments will need to respond to the needs of these more demanding customers by providing stronger customer support, including team members with real-time access to the data necessary to estimate and quote future service charges or assist with any inquiry regarding claims or payments.

As patients come to view themselves as direct purchasers of healthcare services, they also will demand more timely, technology-enabled, and user-friendly scheduling end pre-registration services. To attract and maintain a strong patient base, revenue-cycle leaders will have to eliminate registration delays, inconvenience, and all other obstacles to a patient's access to their organizations' services.

In addition, as CDHPs proliferate, prorating insurance plan coverage will become an increasingly complex process. General benefits will no longer apply to all members of a given employer's benefit plan. Rather, each patient has the opportunity to select a custom benefits package. This new situation underscores the need for timely and accurate insurance benefit verification and the effective storage and retrieval of benefits information.