EXECUTIVE SUMMARY
Patients expect quick and accurate cost estimates for scheduled procedures. To give accurate price quotes, patient access can do the following:
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Instruct patients to get CPT and diagnosis codes from their physicians.
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Ask if patients had a recent service to count toward their deductible.
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Inform patients that if services change, out-of-pocket costs also will change.
(Editor’s Note: This story is the first of a two-part series on price transparency and patient access. This month, we cover processes to give patients cost estimates. Next month, we’ll explore how recent legislative and regulatory developments will change patient access.)
Recently, every Oregon hospital committed to providing cost estimates for scheduled procedures within three business days. Most patients, however, aren’t willing to wait nearly that long.
“What we are seeing is patients expect to get estimates whenever they want,” says David Kelly, director of revenue cycle at Mary Rutan Hospital in Bellefontaine, OH. Patient access fields many phone calls from price-shopping patients. “We get a lot of prospective inbound calls. People are looking for estimates and comparing us to a competitor,” says Kelly.
Mary Lee DeCoster, a Phoenix-based revenue cycle consultant, says the ability to provide cost estimates to patients specific to their coverage requires the following:
• Patient access departments need a database with the contract terms and rates.
• Departments need to send an electronic data interchange query to the payer to confirm the patient’s coverage and the status of satisfying the deductible.
“Quoting chargemaster rates will not fulfill the request,” warns DeCoster.
• Departments need to meet the needs of different generations within the patient population.
“Millennials want information exchange using handheld technology, while Baby Boomers prefer face-to-face or telephone conversation,” says DeCoster.
Hospitals clearly need technology as part of the solution. “An out-of-date printout of an Excel spreadsheet kept in the drawer will no longer meet the need to respond to the consumer’s question, ‘How much will this cost me?’” DeCoster says.
An Immediate Answer
Patient access employees at Mary Rutan Hospital give most price-shopping callers an immediate answer.
Kelly says, “If we have all the data in hand that we need to generate an estimate, we can do it in real time with somebody on the phone.” (See related story later in this issue on informing patients that their actual costs might change.)
Previously, individual areas were fielding price-shopping calls. For example, if patients wanted to know out-of-pocket costs for a stress test, they called cardiology. “Schedulers aren’t necessarily experts in price estimates,” notes Kelly. “This alleviates the stress of dealing with those incoming questions.”
Here is how the department handles price estimates:
• Patients are asked for CPT codes, diagnosis codes, and whether the physician expects the patient will need admission or be treated as an outpatient.
The estimate is only as good as the numbers that were plugged in. “If an ancillary test is commonly performed with the CPT, the team members have the option to assume it will be done,” says Kelly.
• Deductibles are taken into account because these might change the patient’s preferred timing for the service.
“Some patients want to schedule a service within a calendar year because they’ve already met their deductible,” says Kelly. Others want to book it for the following calendar year because they’re anticipating other costly medical procedures.
“Since we do non-centralized scheduling here, if a patient wants to move an appointment based on what they learn about the cost, we, unfortunately, have to route them back to the scheduling department,” says Kelly.
In some cases, the deductible already was met, but patient access staff can’t tell because the service was so recent that it wasn’t yet processed. To address this problem, staff members ask patients if they’ve had a recent service. “We can only go off our claims data,” Kelly says. “If another provider has not yet submitted a claim, we may estimate that they’ll owe $1,000, and they end up owing us nothing.”
If the patient believes he or she has met the deductible, a staff member can key it in as though it were the case, to show how it would affect things financially. “Then we may be just talking coinsurance or copay. We can change our estimate on the fly,” says Kelly.
• Patient access staff members acknowledge that they can’t always compete on cost alone.
For example, an MRI likely costs much less at a freestanding center. “We can’t compete with an imaging center on price alone,” says Kelly. “Hospitals have a higher cost basis.”
Patient access doesn’t say anything to disparage other providers on the phone calls, however. “We would hope the patient is making a full assessment — not just the cheaper vendor, but the best value,” says Kelly. “But ultimately, it’s the patient’s decision.”
