Code Green

Man gets $350,000 heart bypass by stealing friend's identity

Source:  Chicago Tribune

John Parsons apparently believed he would die without heart bypass surgery. To get it, the uninsured 57-year-old ex-convict took a step that has hospital officials shaking their heads--he managed to pass himself off as a mentally-disabled friend and, using the friend's Medicaid card, obtained the surgery. Now, officials at Chicago's Northwestern Memorial Hospital are stuck with a big bill and a lot of questions as to how Parsons pulled it off.

According to the authorities, Parsons got the surgery at Northwestern in 2007, generating about $350,000 in expenses. When bills started arriving at the home of the friend, Philip Johnson, Johnson's live-in caregiver discovered the alleged scam and notified officials. Parsons has since admitted stealing Johnson's identity. Northwestern, for its part, has agreed to cover the cost of the surgery so Johnson won't be responsible for it.

What has healthcare officials puzzled is the extent of the apparent deception. To get the heart bypass, doctors would have needed a lot of clinical information, including patient blood type, cardiac history, medical history and more, records that would be very difficult to fake, notes CMS spokesman Jeff Nelligan. Northwestern continues to investigate the incident.

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Edna Gets It - My Husband Doesn't

By Kari Kemper, Provider Advantage

Same child, different hospital.  Totally different registration experience.

My youngest son had a scheduled procedure done this week at our local Children's hospital.  This was an outpatient stay.

As you may recall, I have been through healthcare registration experiences before, duly noted in this post, I Have Issues.

Now, when we arrived in Registration, we were greeted by a lovely woman, who clearly knows her job, and presents a level of professional compassion.  As my husband and I sit to register our son, my husband is pointing out the different "fun" kid items in the room, clearly trying to distract my son from what is about to happen.  I am, on the other hand, watching Edna very closely to see how she actually registers a patient.

She asked me to recite my phone number and address.  Yes!  I had to recite it vs. giving her a nod of my head signalling that what she said to me was correct.

Then, she said, "Your co-pay is $350."

I was overjoyed.  My husband was not.

He just looked at her.

She looked back at him stating that the hospital does take personal checks, VISA and MasterCard.

He asked if he could get a bill, however she responded that they prefer to collect payment upfront.

I looked at my husband in confusion.  Has he not been listening to me all these years as I wax poetic about revenue cycle management?  Does he not work for the hospital mentioned in my previous post and therefore was subject to my criticism that they would not take my money when I offered it to them willingly?

So, I proceeded to tell my husband that on average, it costs a hospital $25 to bill a patient ONCE.  Edna looked at me and said,

"You got it.  And most patients do not realize this fact.  It is expensive to bill a patient."

As we left Registration, I questioned my husband as to why he wanted a bill, and he said,

"I know the hospital won't do anything.  I can wait until I receive the third bill before I pay."

I was shocked to hear that my husband does this.

He continued, "This way I can keep the money in my bank account longer.  Why hand it over when I am not being forced to do so?  Plus, I will continue to receive other bills for the same procedure - lab fees, physician fees, hospital and supply fees - I am not getting one clear document from the very beginning.  I can wait because I can."

Healthcare is a Consumer Market

By Kari Kemper, Provider Advantage

Health care is a consumer market, according to the 2008 Survey of Health Care Consumers, which provides a comprehensive assessment of consumer behaviors, attitudes and unmet needs related to health, health care and health insurance.

"Health care providers might be inclined to think of consumers as patients - passive, somewhat inactive, dependent on doctors to make decisions for them, and often non-adherent to treatment recommendations.  That perspective is short-sighted...."

"They want greater access to information....moving to an consumer orientation means viewing physicians as coaches rather than decision makers, enabling consumers to consider all available options, shifting more responsibility for adherence and outcomers to consumers and expecting consumers to be fully aware of and accountable for spending."

"They have an insatiable appetite for information and they are looking for a source that provides what they need in a useful and timely manner."

Is your registration department ready?

Interesting findings in the study:

• Consumers believe that hospitals are an important community resource...
• Only 7% of consumers say they are financially prepared for their future healthcare needs.  By contrast, 93% say they are insecure about their ability to pay for their future healthcare needs
• 52% of consumers with insurance say they understand their insurance coverage, but less that 1 in 10 consumers are confident they understand their coverage well
• Consumers are paying attention to prices for their prescriptions, office visits, hospital services, and insurance premiums.  They want tools to help them know in advance what those costs will be.

More Hospitals Using Personal Data to Assess Ability to Pay

Wall Street Journal, March 18, 2008

A growing number of hospitals are mining patients' personal financial information to figure out how likely they are to pay their bills. Hospitals say the practice helps them identify which patients to pursue actively for payment, and allows them to figure out more quickly which patients are eligible for assistance programs. Consumer advocates, however, say the practice creates the potential for hospitals to misuse the information by denying or cutting back on patients' care if the hospital decides the patient may not be able to pay.

To continue reading this article, go here.

Present On Admission Deadline Nears

By Kay Jackson, Iatric Systems

Beginning April 1, 2008, if hospitals do not report a valid POA code for each diagnosis, the claim will be returned for correct submission. CMS expects to save $20 M a year based upon adoption of the POA indicator and that savings may in fact be understated.  Coding professionals will be central in the POA abstracting process and will need to work closely with hospital staff to create complete and accurate documentation. The CMS web site, listed below, provides all necessary information for hospitals reporting hospital-acquired conditions and present-on-admission indicators. The site outlines the background of the new present-on-admission regulation and explains what information hospitals need to submit as well as the proper codes. Two codes that need clarification are  U and W and CMS has not yet had a chance to tell hospitals if there will be a cap on the frequency with which they can use these two codes. To complicate the POA possible financial impact, these “never” events as they have been labeled, will also not be reimbursed by some commercial plans and the list is growing.  In fact, Massachusetts hospitals will adopt a no-charge policy for certain adverse patient events beginning this year.

POA CMS website:  http://www.cms.hhs.gov/HospitalAcqCond/

Present On Admission Workbook Produced by AHIMA: 
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5499.pdf
http://www.cms.hhs.gov/Transmittals/downloads/R1240CP.pdf

A Healthy Revenue Cycle Begins with Registrars as Patient Advocates

By Sherrie Adams, Provider Advantage

So much has been written about the importance of revenue cycle technology and process improvement as it relates to hospitals’ financial sustainability.    In the face of decreasing commercial and government reimbursements and increasing uncompensated care,  there is no doubt that a high performing revenue cycle is essential.  Going beyond the traditional registration process by proactively knowing your patient and understanding more of what what they need and want from you, provides a positive customer experience.

CDHP allows patients to be selective in choosing a facility based on medical outcomes and price; thus shifting the delivery of healthcare to a more retail environment.  While this shift is fundamentally changing the revenue cycle process of hospitals, as patients make decisions based on quality of care and price,  what is not changing is the overall patient expectation in being treated with respect and compassion.

Implementing a compassionate revenue cycle begins with registrars as patient advocates.  Do you have solutions in place that redefines your revenue cycle while improving patient satisfaction?  Let’s examine patient friendly processes that will enhance your revenue cycle initiatives with your patient in mind:

• Multiple revenue cycle functions on one platform to reduce patient wait time and pull applicable information into a single patient-centric view.  When applications are pulled together prior to the patient’s arrival, this shows that your facility has planned for and is prepared to receive the patient.
• Ability to properly sequence insurance plans to maximize the reimbursement based on billing the appropriate plan.  This prevents rebilling and payment delays, and lessens the amount billed to your patient
• Use of scripting tools helps staff communicate more effectively with patients
• Automated eligibility to verify patient coverage.  This is a necessary service you should provide to your patients.  It allows your hospital to proactively identify no coverage due to change in insurance plan or discrepancies in patient information that may result in a claim denial.  Determining whether plan coverage is an HMO or discovering the existance of other insurance plans allows for proper insurance carrier billing and prevents inaccurate patient billing
• Using additional data sources to identify other names and SSN that may be associated with the patient’s ID, highlighting possible identity and medical fraud.  By checking eligibility and demographic sources, you are not only making sure you “know” to whom you are providing service but providing additional information and comfort to the patient that nobody else is using their information
• Financial assessment helps staff understand the patient’s financial situation, providing appropriate recommendations to assist the patient in account resolution.  Whether the resolution is medical debt financing, payment arrangements or referral for Medicaid or charity assistance, information is key to understanding what financial assistance the patient needs from your organization
• Automated tools that not only address state Medicaid qualifications and your hospital charity quidelines but go beyond traditional financial solutions, identifying other 3rd party financial resources.  This increases patient satisfaction by showing that the hospital is addressing their financial pressures along with their medical needs
• Regardless of insurance coverage, deductibles and co-pays, patients want to know how the procedure is going to affect their financial health. Registrars need to provide out-of-pocket information quickly and patients deserve a level of confidence that the information they are given is accurate. 

I Have Issues

By Kari Kemper, Provider Advantage

Several years ago, I visited my local emergency department (ED) with my youngest son.  Seems as though his lip made direct contact with his older brother’s head, causing quite a gash. 

Entering the ED, my main goal was to make sure my son was tended to.  However, being in the healthcare revenue cycle industry, I was curious to see how this particular ED, which is part of a major hospital system in a large metropolitan area, would handle processing my information and asking for payment.

According to EMTALA, when a patient enters the ED, they must be triaged and in stable condition before any insurance or financial information can be requested by the hospital or verified. 

And this particular ED followed EMTALA to the letter.  My son was triaged, stability confirmed, and we were sent back out into the waiting room to “register”.

Sitting in the registration booth, the registrar asked for my son’s name and birthdate to pull up his patient record.  Accessing his record, she recited the address in the file and asked me if this was accurate.

Issue #1:  Registrars should always ask the patient or patient representative to recite their address to the registrar vs. reading the address to the patient.  Many times patients are distracted over their health issue and don’t really hear the registrar.  They end up confirming inaccurate information which causes delays in billing and payment.  Ideally, the registrar would enter the recited address and verify immediately against real-time data to confirm the accuracy and validity of the patient’s demographic data.

Knowing that insurance eligibilty information was coming next, I had my insurance card ready.  Again, the registrar asked me if I had XYZ insurance.  I confirmed verbally and showed her my card.  She glanced at the card stating she was sure it was alright and proceeded to have me sign a few consent forms.  I told her that per my card, I have a $50.00 emergency department co-pay and that I can pay by check or credit card.

She responded that they would bill me.

I told her that I wanted to pay now.

She expressed that the Billing Department handles this and I need not to worry about payment at this time.

I pushed further, telling her that it would be better for me to pay now, and in turn it would benefit her hospital to have money in hand immediately, thus eliminating the overhead costs of billing.

She would not take my money.

Issue #2: Insurance information changes rapidly whether it is employer, employee or insurance company initiated.  What is in the patient record now, may be incorrect tomorrow.  It is recommended to verify eligibility real-time while the patient is presenting to accurately assess insurance eligibility data.  From the returned data, other processes can be launched such as collecting payment (ahem), sending the patient to financial counseling, qualifying for Medicaid, etc…all of which will bring revenue into your door faster.

Now, this was several years ago.  Surely hospitals have caught on right?

Not so fast.

Yes, insurance eligibility verification and demographic validation are becoming more mainstream in hospitals today.  However, patients now expect more.

Last December, my physician ordered additional testing for me after a routine office visit, which required making an outpatient appointment with imaging.

I was handed the appropriate paperwork and told to pick up the scheduling phone in the hallway to schedule the procedure.  Very convenient.

During this scheduling process, the scheduler asked for my insurance information.  As I gave her the information, I asked her what my co-pay would be for this event.  She said she did not have that information. 

Issue #3:  Verifying eligibility during the scheduling process allows the scheduler to request from the patient to bring in payment for the co-pay/deductible during the time of the procedure, thus reducing billing costs and increasing cash flow.

Checking in at registration a week later, the registrar read my address to me (it was incorrect), and confirmed with me verbally that I had XYZ insurance.  I asked what my co-pay was, and she said she did not have access to that data.  I told her that I would like to know what the procedure would cost me out-of-pocket (pricing estimation) and she was unable to provide that financial data. 

I was ready to pay the co-pay and out-of-pocket costs immediately, or at a minimum, set up a payment plan, and was unable to do so.

Issue #4:  Consumer driven healthcare is on the rise. At some point during the registration process, the patient may ask you how much they will have to pay the hospital for their medical procedure.  Hospitals need to evaluate key data components – hospital charges, patient charges, and the negotiated contract pricing between the hospital and the payer.  Summarizing the total charges, benefits and estimated out-of pocket expenses allows the patient to financially plan.

Patients do not want to know how much the procedure will cost, they want to know how much it will cost them, essentially categorizing healthcare as a transaction.  In order to improve their revenue cycle, it is necessary that hospitals change the patient experience on the front end, empowering both the healthcare industry and the patient, allowing for financial planning with no surprises.

I am still waiting for my bill.  And I bet I will be surprised.

When it Comes to Patient Registration,First Impressions are Lasting Impressions

By Dale Wolf, Cincom Systems

Hospital registration processes create the patient's first impression of a hospital experience. It should demonstrate precision, professionalism and not result in future billing confusion for the patient. It should also be seen by hospital CFOs as a critical component in the hospitals' revenue cycle operations.

Every business -- hospitals included -- are now measured by customers (patients) based on the total customer experience. Obviously a perfect clinical outcome is the main measure of a customer experience. But the experience is composed of many other factors, as well. And they start in the lobby of the hospital, are impacted by the registration process and registration staff and end when the patient leaves the hospital.  But for far too long, the evolution of hospital patient access processes have lagged behind that of other areas of hospital financial management. This is now changing as new proceesses, technologies and staff recruitment and training in patient access have elevated registration and given hospitals the opportunity to present a better first impression to patients.

Re-Thinking Your Eligibility Process

By Kari Kemper, Provider Advantage

In today's tumultuous healthcare climate, establishing responsibility for payment, accurately billing and collecting on services rendered, and maintaining a patient-friendly billing environment while increasing the hospital's bottom line is difficult. The majority of hospitals have gaps in their revenue-cycle processes. A high-performing revenue-cycle strategy is necessary to drive top performance at the front-end, while reducing back-end rework.

To continue reading this article, go here.

Finding Your Way Through the Registration Maze

By Chris Woodhead, Cincom Systems

It always amazes me just how much information must be gathered and processed at patient registration time; information such as insurance plan code, insurance eligibility, demographics, credit risk, charity availability, deductible amount and much more. Patient registration not only involves the creation of the patient's medical record, which must be accurate in order to provide appropriate treatment and care, but, in addition, a healthcare provider's ability to collect payments directly correlates to an efficient and accurate registration process......

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