Moving Collections Upfront:

Moving Collections Upfront:

Thomas Jefferson University Hospitals Transforms Processes and Culture to Drive Patient Experience, Increase Revenue

Introductions

Jefferson University Hospitals

• Lori Szymonowicz, CRCE- I

– Senior Director, Patient Financial Services

• Barbara Rubino, CRCE – I

• About Jefferson University Hospitals

• Challenges in revenue cycle optimization

• Process improvements

– Point of service collections

– Financial assistance screening

– Patient experience

• Changing the culture

• Financial outcomes • Future state

Agenda

About Jefferson

University Hospitals

• Serves patients in Philadelphia and the surrounding communities in the Delaware Valley

• 4 primary sites with over 1,020 beds • Named 17th best hospital in the country • By the numbers:

– 7,200 employees – 1,176 medical staff – Admissions: 46,386 – Outpatient visits: 475,031

Challenges in Revenue Cycle

Optimization

5

• Regulatory impacts

• Reduced payer reimbursement

• Payer mix

• Higher patient liability

Overall Outlook for Providers

Negative financial pressures Increasing consumer liability Declining insurance payments Increasing cost pressure Estimated that

30%

$200 Billion

Regulatory Pressures

7

Regulatory Pressures:

Federal Deficit Spending Cuts

• January 2013 Deficit Deal – over next 10 years, additional $30 billion

reduction in reimbursements

– $15 billion in Medicare cuts over the next 10 years (physician SGR fix)1

– $10.5 billion overpayment recoupment over next three years1

– Medical disproportionate share payments to rural hospitals of $4.2 billion over the next decade1

– $4.9 billion reduction in end stage renal disease funding over the next decade1

• March 2013 Sequester

– 2% cuts in Medicare payments to all providers estimated at $10 billion over the next year2

Regulatory Pressures

Federal Deficit Spending Cuts

9

Obama proposes $400B in Medicare payment cuts over the

next decade for his FY 2015 budget

Payer Mix: Economics of Self-Pay

and the Affordable Care Act

• 11 million people will be covered by Medicaid or CHIP1 • 25-28 million people will be covered in the health insurance

exchanges (high deductible health plans)1

• Hospital readmission penalties – reduced revenue

• Value based purchasing program – reduced revenue

• Insurance carrier taxes for ACA passed onto providers and patients

$155 billion in provider payment cuts to Medicare over 10 years to pay for the legislation

Economics of Self-Pay

Increasing Patient Responsibility

11 Consumer Out-of-pocket Payments for National Health Expenditures, 1990 – 2010(1)

$0 $40 $80 $120 $160 $200 $240 $280 $320 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 Bi lli o n s

Source: Centers for Medicare & Medicaid Services, Office of the Actuary. Data released January 9, 2012.

(1) CMS completed a benchmark revision in 2009, introducing changes in methods, definitions and source data that are applied to the entire time series (back to 1960). For more information on this revision, see http://www.cms.gov/nationalhealthexpenddata/downloads/benchmark2009.pdf

Growing Self-Pay: Increasing

Patient Responsibility

National Health Expenditures: Tables, 2012

Growing Self-Pay: Increasing

Patient Responsibility

13 Kaiser Family Foundation & HRET: “Employer Health Benefit Survey.” August, 2013

Growing Self-Pay:

Growing Self-Pay:

Patient Financial Stress

15 Kaiser Family Foundation: “Medical Debt Among People with Health Insurance.” January, 2014

Process Improvement(s)

17

• Reconfigured collections process so staff could speak with patients about paying earlier, resulting in more productive co-pay and deductible collections and improved patient awareness of payment responsibility

• Leveraged technology to help patient access staff create tailored collection strategies, reducing underpayment risk

• Maximized patient experience – no sticker shock when they receive their bill

• Optimized data to identify patients most receptive to collections calls

• Educated staff in order to engage and drive ownership of the process

– Role playing and scripting

– Contests – (mini events to motivate staff)

 Until hardwired

– Accountability

 Revised QA scorecard

• Educated patient population

 Return patients coming with checkbook in hand!

Culture Change

Culture Change

19

• Identified areas of opportunity

– Bad debt placements by hospital service to focus collection efforts

 Wake up call for staff!

• Developed action plans for targeted areas

• Tracked and posted results weekly

– By collector, department

 Motivated staff to excel

2013 -2014 TJUH Admissions Dept.

PERFORMANCE SCORECARD Department Report

Indicator Expec ted Trend

CC Trend Baseline Target Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Patient - Activity & Growth

Press Ganey QA Scores 95.6 Productivity Standard 100% POS Collections 400.00 ABN Medical Necessity Y Wait Times Y Duplicate Medical Records Y MSP Obtained Y Employee monthly registrations per Registrar productivity ↑ 4 per hour 4.1

Leveraging Technology

22

• Trained the front end staff for roll-out starting last year

• Users view pop up window showing Open Balances, scripting help, and the patient’s propensity to pay to help with collections

• Users can also print a patient friendly letter including instructions on how to pay or call the business office for more information

Point of Service Collections:

Open Balance Display

Technology Supports Process

24

• Build rapport with the patient

– Call them by name

• Be confident and friendly as you talk to the patient

• Don’t be afraid to ask “How would you like to take care of

your co-pay/deductible/ balance due charges today?”

– Pause to wait for patient’s answer

• EDUCATE the patient on expectation of paying any co-pay

and open balances owed during every conversation

Scripting

26

Front end payments (POS collections) increased 31% after implementation and have maintained that increase

POS Collections Results

28

31% Increase

• More concerted effort

was kicked off Jan 1, 2014

• This resulted in a 40%

increase over the previous three-month period

• Automatic worklist generation for medical assistance application or hospital financial counselors

• Payment options based on financial screen

• Identify marketplace insurance candidates

• Facilitate COBRA assistance

• Hospital charity care

Financial Counseling Tools

30

• MA Vendor and Jefferson financial counselors work in tandem using the Experian Health worklist

• Custom rules help screen patients to the right programs more quickly, helping increase reimbursement and/or charity write-offs

• Reporting example showing number of patients screened and outcomes

• MA vendor inpatient/outpatient surgical MA applications increased 31%

– Referrals are made more timely with new worklists driving increase of MA potentially eligible

• MA vendor ER cases decreased 9%

– Cases that were screened to be ineligible for MA

 Decreased hospital’s letter expenses

Compared Aug. 12 to Jan. 13 prior to FAS Screening to Feb. 13 to July 13 after FAS Screening

Results – Financial Assistance

Screening

32

Charity Care/ Bad Debt Write Offs

• FY 2013 to FY 2014

comparison

• Charity write-offs

COBRA Program Results

34 Represents premiums paid for 17 patients 2012 - 2014

• Re-structured the dialer jobs to create unattended messaging vs. manual and progressive dialing

– Outbound calls increased 105% on average for the first three months

– Calls went from 8,210 to 16,894 per month

 While staff reduced by 2 collectors

– Inbound calls increased 1,100 per month on average

– IVR Payments increased 41%

– Calling the right patients at the right time reduced complaint escalations

Collections Optimization

36

• Marketplace premium default predictor

• Automated pre-service collections

Future State

38

Thank You!

40 Lori Szymonowicz

Senior Director, Patient Financial Services

[email protected]

www.jefferson.edu

Barbara Rubino Director, Patient Access

[email protected]

Policy No: 106.14

Original Issue Date: 12/30/1998

Review Date: 04/01/2014

Revision Date: 04/01/2014

HOSPITAL POLICIES & PROCEDURES

Category: Financial

Title: CHARITY CARE AND PARTIAL CHARITY CARE

Applicability: Thomas Jefferson University Hospitals, Inc.

Contributors/Contributing Departments:

Business Services, Compliance, General Counsel

PURPOSE

Thomas Jefferson University Hospitals, Inc. (“TJUH”) is committed to treating patients with dignity and consideration regardless of their financial circumstances.

POLICY

It is the policy of TJUH to provide financial assistance in the form of Charity Care and Partial Charity Care to patients residing in its Local Service Areas (see Attachment 1) who require Medically Necessary care and who are ineligible for Medicaid; have exhausted or limited insurance benefits; and meet household income and asset criteria or Medical Indigence standards as set forth in this policy.

TJUH considers each patient’s ability to pay for his or her Medically Necessary medical care, and extends Charity Care or Partial Charity Care to eligible patients residing in its Local Service Areas who are unable to pay for their care in accordance with this policy. This policy sets forth the eligibility procedures for Charity Care and Partial Charity Care in compliance with

applicable federal, state, and local law.

Patients seeking emergent care at TJUH shall be treated without regard to their ability to pay for such care. TJUH shall operate in accordance with all federal, state, and local requirements for the provision of health services, including screening and transfer requirements under the Federal Emergency Medical Treatment and Active Labor Act (EMTALA). See Policy #113.36.

DEFINITIONS

Charity Care: 100% free medical care for Medically Necessary services provided by

TJUH. Patients who are Uninsured or Underinsured for a medically necessary service, who are ineligible for governmental or other insurance coverage, and who have family incomes not in excess of 200% of the Federal Poverty Guidelines are eligible to receive Charity Care. (See Attachment 2).

Medically Indigent: Patients who, despite their income, have a low level of liquid assets such

that payment of their medical bills would be seriously detrimental to their basic financial well-being and survival.

Medical Necessity: Any diagnostic study, procedure or treatment needed to prevent, diagnose,

correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause suffering or pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, if there is no other equally effective, more conservative or less costly course of treatment available.

Partial Charity Care: Care at a discounted rate for Medically Necessary services provided by

TJUH. Patients who are Uninsured or Underinsured for a medically necessary service, and who have family incomes in excess of 200%, but not exceeding 500%, of the Federal Poverty Guidelines, are eligible to receive Partial Charity Care in the form of a discount of between seventy percent (70%) and ninety percent (90%) off inpatient and/or outpatient charges. (See Attachment 3). However, patients who would otherwise qualify for Partial Charity Care but who have sufficient liquid assets available to pay for care without becoming Medically Indigent are not eligible for Partial Charity Care.

Presumptive Charity Care Eligibility: A determination that a patient is presumed eligible for

Charity Care when adequate information is provided by the patient or through other sources which allow TJUH to determine that the patient qualifies for Charity Care. (See Attachment 4)

Uninsured Patient: An individual who does not have any third-party health care coverage from

either: (a) a third party insurer, (b) an ERISA plan, (c) a Federal Health Care Program (including without limitation Medicare, Medicaid, HealthChoices, CHIP, adult Basic and TRICARE), (d) Workers’ Compensation, (e) Healthcare Reinsurance or Savings Accounts, or (f) other coverage, for any part of the bill, including claims against third parties covered by insurance to which TJUH is subrogated, but only if payment is actually made by such insurance company.

Underinsured Patient: An individual who has medical insurance coverage that is limited in the

scope of covered services or policy maximums such that his or her medical bills are not fully covered.

PROCEDURE

I. Identifying Patients Eligible for Charity Care or Partial Charity Care

A. Patients who qualify for Charity Care or Partial Charity Care shall be identified as

soon as possible, either before or after care is provided.

B. If it is difficult to determine a patient’s eligibility prior to the provision of care, such

determination shall be made as soon as possible, but no later than 18 months after the provision of care.

C. TJUH shall publish and post signage and internet notices to advise patients of the

availability of Charity Care and Partial Charity Care in the English, Spanish, Chinese, and Vietnamese languages.

II. Dissemination of Eligibility Information

A. Patients identified through the registration process who appear to be Uninsured or

Underinsured and who indicate their inability to pay for Medically Necessary services shall receive:

1. A packet of information that describes this Charity Care policy and relevant

procedures, including an application for financial assistance and/or,

2. Financial counseling, including an application for financial assistance.

B. Translation assistance to complete necessary forms is available for those patients

who are not proficient in reading, writing, or speaking English.

C. In order to allow TJUH to properly determine Charity Care or Partial Charity Care

eligibility, documents provided to patients by TJUH shall be written in English, and translation assistance will be provided as needed.

III. Eligibility Methodology

A. TJUH shall adhere to an established methodology to determine eligibility for

Charity Care and Partial Charity Care. The methodology shall consider whether health care services meet Medical Necessity criteria, as well as income, family size, and resources available to pay for care.

B. All available financial resources shall be evaluated before a determination regarding

Charity Care or Partial Charity Care is made. TJUH shall consider the financial resources of the patient, as well as other persons having legal responsibility to provide for the patient (e.g. parent of a minor, spouse).

C. Copies of documents to substantiate income levels and assets shall be provided by

the patient/guarantor (e.g.: W-2, Tax Returns, Pay Stubs, Bank Statements)

D. The patient/guarantor shall be required to provide information sufficient for TJUH

to determine whether he or she is eligible for benefits available from insurance, Medicare, Medicaid, Workers’ Compensation, third party liability, and other federal, state, or local programs.

1. If in the course of evaluating the patient’s financial circumstances it is

determined by TJUH that the patient may qualify for federal, state, or local programs or insurance coverage, financial counseling will be provided to assist patients in applying for available coverage. Charity Care and Partial Charity Care will be denied to patients/guarantors who do not cooperate fully in applying for available coverage.

2. Patients with Healthcare Reinsurance or Medical Savings Accounts are

insured for purposes of this policy, and the amount on deposit will be considered as an available resource toward payment for Medically Necessary services.

3. If a patient has a claim (or potential claim) against a third party from which

the hospital's bill may be paid, the hospital will defer its Charity Care determination pending disposition of the third party claim.

E. Eligibility for Charity Care or Partial Charity Care shall be determined using a

sliding scale based on 200-500% of the Federal Poverty Level Guidelines as published annually in the Federal Register, as well as consideration of available assets and any extenuating circumstances. (See Attachment 3)

F. Eligibility for Charity Care and Partial Charity Care will extend for up to 180 days

from the date eligibility is determined.

G. Patients/guarantors shall be notified in writing when TJUH makes a determination

concerning Charity Care or Partial Charity Care.

H. In the event that TJUH determines that a patient is ineligible for Charity Care or

Partial Charity Care, the patient may appeal that decision in writing to the Vice

President, Revenue Cycle within thirty (30) days following receipt of the bill for which financial assistance has been requested. Failure to so appeal will result in the decision becoming final. The determination of the Vice President, Revenue Cycle shall not be subject to further appeal.

I. This policy covers hospital services only. Services provided by physicians and other

non-hospital services are not covered by this policy. Patients seeking a discount for such services should contact the physician or other provider directly.

J. All information obtained from patients and guarantors shall be treated as

confidential to the extent required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

IV. Guidelines for Collection

The following collection guidelines shall apply to hospital bills for patients eligible for Partial Charity Care:

A. Patients extended Partial Charity Care must sign a written agreement to pay the

amount of the hospital bill remaining after application of the Partial Charity Care discount. The patient will receive a bill showing charges, the Partial Charity Care discount, and the amount due. TJUH will negotiate and agree upon a reasonable payment schedule with the patient/guarantor.

B. Payment will not be pursued in a manner that will render the patient Medically

Indigent.

C. Lawsuits shall not be instituted by TJUH unless adequate written opportunity to

resolve the unpaid amount has been ignored or rejected by the patient/ guarantor. TJUH General Counsel shall pre-approve all lawsuits.

D. If there is a reasonable belief that there are income or assets available to fulfill the

payment obligation, TJUH will not take legal action to place a lien, seize property or garnish wages.

E. TJUH will not require sale or foreclosure of a primary residence with a market

value of less than $250,000 except in special circumstances approved in writing by TJUH’s General Counsel.

F. When appropriate under applicable law, TJUH may pursue debt collection from

financially responsible family members.

V. Presumptive Charity Care Eligibility

A. A patient may qualify for Charity Care if the patient meets presumptive eligibility

guidelines. A patient may be presumed eligible when adequate information is provided by the patient or through other sources which allows TJUH to determine that the patient qualifies for Charity Care. ( See Attachment 4)

B. Presumptive eligibility only applies to Charity Care eligibility determinations, and

may not be used for Partial Charity Care eligibility determinations.

VI. Medical Indigence

A. TJUH shall make a decision about a patient/guarantor’s medical indigence by

reviewing relevant documentation concerning any circumstance which would demonstrate that a patient should be considered eligible for a Charity Care or Partial Charity Care on the basis of Medical Indigence.

B. The patient shall apply for Charity Care or Partial Charity Care in accordance with

the Charity Care policy.

C. TJUH shall obtain or generate documentation that supports the Medical Indigence of

the patient. The following are examples of such documentation:

2. Information related to patient/guarantor drug costs.

3. Information demonstrating multiple instances of high-dollar patient medical

liabilities.

4. Other evidence of high-dollar amounts related to healthcare costs, such as

documentation that an HSA that has been fully expended.

VII. Charity Care Exception Review

A. The TJUH Vice President, Revenue Cycle and Senior Vice President for Finance

and Chief Financial Officer shall meet as needed to evaluate information related to patient accounts that do not clearly qualify under Charity Care or Partial Charity Care eligibility criteria to determine whether Charity Care or Partial Charity Care is

appropriate under the circumstances. The types of patient accounts to be reviewed shall include, but not be limited to:

1. Medically Indigent patients;

2. Patients who do not reside in the Local Service Areas; and

3. Patients who have substantial non-liquid assets.

VIII. Compliance Monitoring

A. The Chief Compliance Officer (CCO) shall periodically conduct audits to ensure

compliance with this Policy.

IX. Amendments/Interpretation

A. This Policy is subject to change without prior notice, is subject to interpretation by

TJUH at its sole discretion, and is not intended to create any contractual relationship or obligation.

B. The Vice President, Revenue Cycle and Senior Vice President for Finance and Chief

Financial Officer shall determine the need for revisions to this Charity Care Policy and shall submit revisions for review to the CCO and General Counsel.

Please see four attachments: 1) Local Service Area by County; 2) Federal Poverty Guidelines; 3) Charity Care and Partial Charity Care Table; and 4) TJUH Financial Assistance Application Presumptive Eligibility.

Attachment 1: Local Service Area by County (PDF)

Attachment 2: Federal Poverty Guidelines (PDF)

Attachment 3: Charity Care and Partial Charity Care Table (PDF)

Attachment 4: TJUH Financial Assistance Application Presumptive Eligibility (PDF)

Original Issue Date: 12/30/1998

Revision Date(s): 02/01/2005, 03/27/2009, 07/28/2009, 03/21/2011, 04/01/2012, 04/01/2013, 04/01/2014

Review Date(s): 07/28/2009, 03/21/2011,04/1/2012,04/1/2013, 04/01/2014

Policy No: PFS050

Original Issue Date:7/31/2011 Review Date: 5/5/14

Revision Date:

HOSPITAL POLICIES & PROCEDURES

Category: Business Services Title: Patient COBRA Benefits

Applicability: Thomas Jefferson University Hospitals, Inc. Policy Owner: Patrice Miller, Nancy Rhodes

Contributors/Contributing Departments:

Case Management, Compliance, Legal, Business Services

PURPOSE

To ensure that any Thomas Jefferson University Hospitals, Inc. (“TJUH”) patient who qualifies for financial assistance under TJUH’s Charity Care and Partial Charity Care policy (Policy No. 106.14) who requires ongoing medical care and may qualify for COBRA Benefits is screened to determine if premium

assistance is appropriate.

POLICY

It is the policy of TJUH to identify any patient for whom COBRA Benefits premium assistance is appropriate. Specific eligibility criteria are established to ensure assistance is provided to patients on a consistent basis. Applications for COBRA premium assistance will be confidentially maintained and premium payments and insurance reimbursement will be reported.

Definitions

A. COBRA Benefits: A health insurance plan which allows an employee who leaves a company to continue to be covered under the company's health plan, for a certain time period and under certain conditions.

B. Ongoing Medicare Care: Non-emergent medically necessary care essential to treat an existing and diagnosed medical condition.

PROCEDURE

I. Eligibility Criteria

A. Patient/guarantor has been deemed to qualify for financial assistance under TJUH’s Charity

Care and Partial Charity Care policy

B. Patients have received emergency room, inpatient, or outpatient services at TJUH and have been diagnosed with a condition requiring ongoing medical care at TJUH facilities or to facilitate transfer to a lower level of care (e.g.: skilled nursing facility, rehab facility).

C. Patient/guarantor is eligible for COBRA Benefits II. Identification of eligible individuals

A. Potentially eligible patients will be identified as a result of interviews with: 1. PATHS Medical Assistance Representatives

2. Social Workers 3. Case Managers 4. Financial Counselors

5. Customer Service and/or Collection Representatives

B. Identified patients will be referred to a Financial Counselor for eligibility screening III. Eligibility Methodology

A. TJUH shall adhere to an established methodology to consider eligibility for COBRA Benefits premium assistance.

1. The patient/guarantor will first be screened to determine eligibility for financial assistance under TJUH’s Charity Care and Partial Charity Care policy.

I. If the patient/guarantor is ineligible for financial assistance under such policy, the patient would be ineligible for COBRA Benefits premium assistance.

II. If the patient/guarantor is eligible for Charity Care or Partial Charity Care under such policy, the patient would be eligible for consideration of COBRA Benefits premium assistance.

2. The patient/guarantor will be screened to determine if the patient/guarantor is eligible for COBRA Benefits.

3. If the patient/guarantor qualifies for Charity Care or Partial Charity Care and is eligible for COBRA Benefits, eligibility for COBRA Benefits premium assistance shall next be determined based on a review of the patient’s anticipated ongoing medical care needs (whether at TJUH facilities or to facilitate transfer to a lower level of care, including, without limitation to a skilled nursing facility or a rehabilitation facility). 4. Finally, TJUH will determine eligibility for COBRA Benefits premium assistance based

upon TJUH’s calculation of the expected reimbursement for medical care that would be covered under the COBRA Benefits (taking into account all deductibles and co-payments) compared to the cost of providing the COBRA Benefits premium assistance.

B. Eligibility for COBRA Benefits premium assistance will extend for up to 90 days from the date eligibility is determined as long as the patient’s physician indicates ongoing care/services are required. If ongoing care/services is needed beyond 90 days, the eligibility criteria will be re-verified and extended in 90 day time periods

C. The financial assistance hereunder is completely discretionary and nothing in this policy shall require TJUH to provide COBRA Benefits premium assistance to any patient/guarantor. TJUH will have no responsibility for failure to maintain COBRA Benefits.

D. All information obtained from patients and guarantors shall be treated as confidential to the extent required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). IV. Approval Process and Monitoring

A. All applications for COBRA Benefits premium assistance shall be reviewed for approval within 2 business days by the PFS Manager and the Director of Credit and Collections.

B. Monthly reviews will be conducted by the Senior Director of Business Services and the Vice President of Clinical Resource Management to ensure consistent application of eligibility determinations.

V. Payment Methodology

1. Establish procedure for monthly check requests payable to the employer/insurer for the eligible time frame(s) utilizing designated department accounting code for Business Services operations.

2. Establish tracking report of all payments made for eligible patients.

Attachment(s):

Citations: Hospital Policy 106.14 Charity and Care and Partial Charity Care

Revision Date(s): 2/3/12

Review Date(s): 2/3/12, 4/1/2013, 5/15/14

Responsibility for maintenance of policy: Lori Szymonowicz, Senior Director, Patient Financial Services