Picking up the bill: Healthcare leaders look to fix the patient financial experience

Geisinger CEO David Feinberg is focusing on better hospital billing.

If healthcare is a consumer product now, then it all boils down to the bill. But confusing formats, separate bills for different doctors, and numbers that are difficult to reconcile with insurer explanation of benefits statements have made the healthcare bill a source of dread.

That may be changing.

As consumerism and value-based pay make it more important to give patients a satisfying experience, healthcare leaders are working to improve bills so they're more comprehensive and better at communicating a patient's financial responsibility.

"These families, these people, all of a sudden have a wrench thrown into their life," said David Feinberg, CEO of the Pennsylvania-based Geisinger Health System. "And then you get home, and you're not sure if you're supposed to pay it or not. It doesn't match the explanation of benefits. What piles up are these bills that don't ease their way at all. They increase their anxiety. They increase their stress. If we're really caring about people, that shouldn't happen."

Geisinger has long been at the forefront of consumer-centric billing approaches, and Feinberg believes it's fundamentally important to get that right.

[Also: This is not a bill: Insurers give explanations of benefits a facelift]

A major component of lessening that anxiety and stress is providing a consolidated bill, encompassing all of the disparate services that have been performed for an episode of care. Presenting it in an easily digestible format doesn't hurt, either.

"When I came here, one thing I tried to do was get a single bill," said Feinberg, "because when someone comes to an emergency room, the last thing they think is that they're going to get multiple bills. There are reasons they exist, but the reality is that it doesn't really make sense to an individual. Two years ago, Geisinger instituted a single bill, which covers the ER doctor, the lab fee, etc. That, to me, is one big advance we've made here."

Another is simply making the bill understandable. This may seem like an elementary initiative, but Geisinger's pilot bill -- written in terms easily decodable by the layman -- has received high marks from patients, and more changes are in the works. Future bills will start incorporating graphs and pie charts so a patient can understand, for example, how much of the bill is part of their deductible.

That plays into Geisinger's push to boost communication and health literacy among its customers.

Barbara Tapscott, Geisinger's vice president of revenue management

More than a statement

Barbara Tapscott, Geisinger's vice president of revenue management, maintains that the health industry needs to adapt some of the practices of the broader consumer industry in terms of providing information to people in easily accessible, easily navigable frameworks.

"It's incumbent upon a health system to provide information and improve health literacy for that population," said Tapscott. "More and more, particularly with high-deductible plans and people new to the insurance market, people expect pricing information similar to what they experience with any consumer goods, where they walk into a store and they ask for a price and they get it.

"We consider the billing experience part of the patient experience because it's that phase in the encounter where people translate the experience into value," she said. "It is incredibly important to provide pricing information for patients and to have the health literacy for the population that didn't have insurance before and doesn't necessarily know how to navigate healthcare."

It's part of what Tapscott calls the "multi-channel" approach to the patient experience. Geisinger has a dedicated unit that financially clears the patient and electronically verifies their insurance and copay. A conversation with the patient follows; they're informed of multiple options by which they can pay, whether it be through an interest-free payment plan or a financial assistance program in the event they're struggling to meet their financial obligations. And Geisinger handles this primarily in-house. The only piece of the puzzle that's outsourced, said Tapscott, is the creation of the payment statement.

Even better

Geisinger's commitment to billing led it to play a vital role in the U.S. Department of Health and Human Services' "A Bill You Can Understand" Design and Innovation Challenge. The winners were announced earlier this year.

The challenge, which began in February 2016, was an open design competition dedicated to helping healthcare systems provide bills that patients could more easily understand.

The program was based on a two-prize structure. HHS wanted to create an opportunity to improve the bill quickly in a way that would be acceptable to healthcare institutions, but it also wanted to encourage participants to rethink the processes behind the bill and to reconfigure the workflow needed to support a product that best served patients. The two prizes, 'Easiest Bill to Understand' and 'Transformational Approach,' each addressed some very specific, research-driven concerns.

[Also: Push for simplified hospital billing can improve collections, experts hope]

For starters, providers often don't inform patients about how their medical care, and the related costs, are distributed among providers. On top of that, the volume of communication can sometimes be overwhelming, with patients receiving documents from insurers, multiple providers and third-party benefits managers for a single event. Confusing terminology and financial unpreparedness were also top concerns.

But perhaps one of the primary concerns had to do with trust. The relationship between providers and payers can result in denial and resubmission of claims, which often undermines patient trust in the accuracy of charges included on the bill. Patients don't often know the full cost of care given the significant differences between the charges appearing on the bill -- reflecting the chargemaster price that would apply to an uninsured patient -- and the amounts their insurance covers. That lack of trust is exacerbated when patients experience charges they simply don't recognize as associated with their care, or when they received duplicate bills.

Having clean processes in place can mitigate some of those issues, though, and Patti Drolet, vice president of revenue cycle management at New York-based Northwell Health, said it's important to nail things down right from the very beginning.

"It starts with the insurance certification of the case, and making sure we have all the right insurance information so we can get all that information to the patient," said Drolet. "It's very important up front that the important data is collected timely and accurately. Once that's done, if they go to the carriers correctly, you minimize the denials. So you're turning the case around faster and there's less cost to collect.

"In reality, if you're registering the person correctly, if you're doing all the screening about the benefits … there are no surprises to the patient," she said. "We let them know that their carrier has an amount allotted to them. That's important."

The HHS has recognized the Clarify platform as one idea to transform the billing experience.

Winning ideas

A simplified, consolidated patient statement is still on Northwell's wish list, and a good source of inspiration may be the two category winners of the HHS challenge.

Prize 1, for "Easiest Bill to Understand," went to RadNet, an operator of free-standing medical diagnostic imaging centers. It aimed to make its bill as concise as possible, and they use color to divide the screen or the page into segments, making it easy to locate and read specific information. The bill clearly presents the payment due, payment options, and insurance details, and the charges are placed in context.

Prize 2, for "Transformational Approach," was awarded to Sequence, an independent design and development agency. It won with its Clarify platform, an online- and mobile-based service that extends a retail model of consumer behavior to medical billing. It presents healthcare services in ways that allow people to search, browse, weigh their options, compare prices and decide how they'll pay.

[Also: Doctors embrace digital tools, want new tech to help with billing, AMA survey finds]

Geisinger participated in the contest in an advisory role as a "Pilot Partner," along with Cambia Health Solutions, Integris Health, MetroHeath, Providence Health and Services and University of Utah Health Care.

"The one commitment that we made to participate in the advisory panel was that Geisinger would implement some of the winning characteristics of the winning design," said Tapscott. "I'm happy to say that my team is working on that. I found the submissions to be innovating, very much looking forward to the future, and to the multiple demographics, from the very young who want to access things on their tablet or mobile phone to the more mature customer. So we are looking at the multi-channel approach."

Those changes should be unveiled by Geisinger early in 2018, she said.

Yet no matter the cosmetic of changes that take place, it all boils down to clarity and support for the consumer. Communication, said Tapscott, is one of the primary responsibilities of any health system.

"Way before the patient walks through the door, we do a number of transactions automatically to verify the patient's insurance coverage, address, etc.," she said. "Then we communicate with the patient, confirm the appointment, then tell them, 'This is how much we expect the insurance will pay, and this is how much we expect you will pay.' Of course, there is always a disclaimer that it's based on what is ordered, and may change. We provide our patients with options to either pay in advance or pay when they leave the clinic, or pay online, so all that communication is there. All of the administrative work has been done when they come in for care."

The conversation continues once the patient has left. Financial counseling is available to all of Geisinger's patients, including financial assistance if they're unable to pay their bill. If the patient is uninsured, the system will work with them to either find insurance or, in the case of Pennsylvania, get them enrolled in Medicaid. That's been an option since 2015, when the state expanded its Medicaid coverage.

It all comes back to customer retention, which has become increasingly important in healthcare, as it has been for decades in much of the consumer world. It's with that in mind that Geisinger launched ProvenExperience, which Feinberg describes as being essentially a money-back guarantee. If a patient feels unsatisfied by any aspect of the care experience, including the bill, they can request a refund of their out-of-pocket expenses. Geisinger has given back about $1 million over the past year through ProvenExperience, but it's proven to be an investment, inspiring brand loyalty among patients. Most patients, said Feinberg, only ask for partial refunds.

They appreciate the respect.

"That would be like if you went into Starbucks, and you don't like the latte, and then they say, 'Sorry, you have to drink it,'" said Feinberg. "They have options. You can't act like a jerk anymore. That's why we think it's important to be as patient and consumer-focused as any other industry. I want to know you as well as Amazon does. We set the bar really high."

Feinberg also had some advice for health systems looking to improve specifically on their billing experiences.

"Listen to your patients," he said. "I would say, follow home one of your patients that you've been treating for a long time and ask if you can see the stack of papers the elderly woman has put on her kitchen table, trying to make sense of it, and sit at the table and listen to the discussion. It's appalling. People need care and time to focus on healing, and we've created an additional burden and hardship."

Twitter: @JELagasse