Pricing Transparency: Focus on the Chargemaster

Transcription

1 Pricing Transparency: Focus on the Chargemaster Presented by Sandy Sage RN, HomeTown Health, LLC August 10, 2017 A PORTION OF THESE MATERIALS WERE PRODUCED PURSUANT TO THE Iowa Small Hospital Improvement Program (SHIP) Grant FY 17, IA Contract #5888SH01 and the Georgia Small Hospital Improvement Grant FY 17 Hospital Transformation Consortium WEBINAR ETIQUETTE All attendees are in Listen Only mode Questions or comments? - Open Questions pane in dashboard. - Type in comments or questions. - Comments will be monitored throughout webinar. - Questions will be addressed at end of the webinar. 1

2 Hospital Transformation Consortium WEBINAR RESOURCES This webinar will be recorded and ed to you to share with others on your team. Handouts are available for download in the Handouts pane and will be ed out to attendees after the webinar. Hospital Transformation Consortium CONTINUING EDUCATION As an IACET Authorized Provider, HomeTown Health, LLC offers CEUs for its programs that qualify under the ANSI/IACET Standard. HomeTown Health, LLC is authorized by IACET to offer 0.1 CEUs for this program. In order to obtain these units, you must: Attend webinar/view recording in its entirety within 30 days Pass online quiz with 80% or better. Complete webinar evaluation. Following this webinar, all attendees who have viewed the recording in its entirety will receive an with a link to the quiz and evaluation. Anyone that misses the webinar can view the recording online, posted on the program Dashboard, for CEUs. 2

3 Hospital Transformation Consortium GROUP PARTICIPATION Are you on this webinar with a group? If so, please enter: first/last names and addresses of those in attendance with you in the Questions Pane. AGENDA Welcome & Introductions Pricing Transparency in Healthcare Upcoming Events & Resources Desi Barrett, HomeTown Health, LLC Sandy Sage RN, HomeTown Health, LLC Jennie Price HomeTown Health, LLC 3

4 Sandy Sage RN Registered Nurse for 25+ years Has worked in rural hospital revenue cycles 17 years HTHU Instructor Currently a Revenue Analyst for HomeTown Health Passionate about saving rural hospitals Love my kids and my cats! Program Goals The goal of the Hospital Transformation Consortium is to build a group of hospitals and other stakeholders that work together to support hospital collaboration and a community of shared best practices in transforming areas of Quality & Data Reporting, Financial Processes, & Technology in order to improve the value for the patient. The Objective of the Pricing Transparency/Chargemaster Series is to ensure that all revenue producing departments will: 1 Understand the Chargemaster and it s importance 2 Be able to self-audit their department s Chargemaster 3 Keep the Chargemaster compliant and Up-to-date 4 Develop tools for Pricing Transparency in your hospital 4

5 Iowa Georgia 5

6 Which of the following information does your hospital offer to patients as it relates to potential prices? What are your hospital's greatest areas of need related to Pricing Transparency and/or your Chargemaster? Do you have plans to expand current pricing transparency efforts? What specifically are you hoping to get out of this program? Making the process simple enough, any staff can acquire a price estimate. Estimating prices specific to that patient's coverage delivered in a cost effective way using a manual process (and not costly software solutions) We would like to expand transparency efforts and increase our availability to move to bundle charging Yes, we would like to expand current pricing transparency efforts. marketing plan we need a Chargemaster review Any information is helpful we would like to know how our prices compare to other hospitals Simplification of the charge master Departmental education on what can be charged and what is non-billable and how to set a price. 6

7 Pricing Transparency Part One Pricing Transparency in Healthcare Learning Outcomes Identify why pricing transparency is important to consumers List the factors that a consumer may use to determine the value of a service. Identify ways to communicate and present pricing information to the consumer. List different variables that may affect pricing Describe the definition of a hospital Chargemaster. 7

8 Price Transparency Information that is readily available to consumers to allow them to understand the value of the services provided and in coordination with other information, will allow them to compare their cost with the cost and quality of other provider s services. The information will help consumers identify the care they want from the provider they want. Why Now? Increased Consumerism New methods of payment Increased Social/Media awareness Price Transparency Increasing Patient Responsibility Increased scrutiny from CMS More Competition 8

9 Poll Question Affordable Care Act The ACA created a more urgent need for consumers to have access to transparent pricing of healthcare services. Rising co-pays and deductibles have increased the out of pocket responsibilities for patients. Most pricing in healthcare is not known until after the service is provided. This is changing as patients see the need to become informed consumers. Even if the ACA is repealed, this will not change. 9

10 Patient Contributions Patients who are employed and get their insurance through the workplace have seen their responsibility increase by 83% Premiums have risen 20% since 2011 for employer sponsored health plans Patient responsibility has risen from 10% of your total revenue to 21% and growing. Patients with insurance through the exchange have even higher amounts of out of pocket responsibility 10

11 State Solutions States are trying to assist patients with their out of pocket costs by enacting laws regarding surprise billing. Surprise billing is when a patient has a procedure at an in-network facility that is done by an out-ofnetwork provider. They receive surprise bills that do not have their innetwork discounts applied. State Solutions Florida enacted a surprise billing law in 2016 and they are going to be launching a pricing website to assist patients in understanding what the pricing is for different procedures. Those prices are based on actual retail charges so patients will still need more information from the provider to determine their responsibility. 11

12 Tools and Solutions Insurance plans and CMS are creating tools for estimates to provide patients with more information. Tools are not exact and are designed to give patients an amount that is an average by location or area. Usually they are retail prices that do not include contract discounts. The information needs to be refined for more accurate estimates at each facility. 12

13 13

14 2018 OPPS Proposed Rule The Secretary shall, for 2018 and each year thereafter, make available to the public a searchable website, the estimated payment amount for an item or service under the OPPS and ASC payment system, and the estimated patient liability of that item or service. The website will be available Early 2018 Difficulty in Transparency Giving accurate price estimates to a patient is difficult and usually only a broad range estimate can be given upfront. What is available is what charges are assigned for items and services. That information is in your Chargemaster. Having an accurate and compliant Chargemaster is more important than ever or you will find yourself defending the charges on a bill with no substantial reasoning to support your arguments. 14

15 Poll Question Transparency Charges Pricing Value Quality 15

16 Charges Chargemaster prices vary greatly from hospital to hospital. Some hospitals do consistent price increases while others will wait years and then do a huge increase. Charges may be set based on a hospital specific algorithm or formula based on the type of service or item. Keeping prices consistent and within market norms will allow you to be competitive. An up-to-date Chargemaster is the foundation for pricing transparency. Pricing Pricing of healthcare services will differ from patient to patient with several influencing factors. Insured Patients: Price is the rate agreed upon between the insurance company and the provider. That price includes any co-pays and deductibles. Uninsured Patients: Price may be reduced if the patient qualifies for financial assistance and discounts are applied based on the Financial Assistance Policy. If a patient doesn t qualify for assistance, the price may be as high as the actual charges. 16

17 Value Value means different things to different people. The value of a service can be based on the following factors: Pricing Convenience of access Safety record Quality scores Prior experience Customer service Clinical outcomes Quality What measures will allow patients to determine the quality of care provided at your hospital? Process Measures Determine how often patients with certain conditions receive evidence based care. (Chest Pain Aspirin, door to door time etc.) Clinical Outcomes mortality, readmissions, patient experiences, care coordination etc. (Hospital Compare) Physician Quality Quality scores reported showing quality of care by physician (MIPS) 17

18 Quality How do you share results of your quality measures with patients? Hospital Compare Community News reports How are they used? Help patients make informed choices Reward high quality performance Compare with other providers Create incentives for improvement Transparency There are multiple consumers that require hospitals to be transparent with pricing and service quality. Patients may be looking for an out-of-pocket price that fits their budget. Employers may be looking for pricing, quality and access to care for their employees. Doctors may be looking for hospitals that provide good clinical care for their patients. All could be looking for a combination. 18

19 What do patients need? Accurate price estimates that are tailored to their individual circumstances. Easy to understand information on the quality of providers. Treatment options Payment options What do patients need? Patient Type Information Needed Health Insurance Plan Coverage Quality data information Plan discounted pricing Out of Pocket responsibility Co-pays, deductibles, OOP Max Medicare Fee For Service Coverage Quality data information Co-pay information (Inpatient amounts are set) Co-pay information (Outpatient based on 20% APC) Secondary coverage information with supplement Uninsured Information on retail pricing Discount information Quality data information Financial assistance information 19

20 What do patients need? Patients Pricing Information Needed Procedures/Medical Treatment Non-urgent requirements for payment Total costs of all related services (facility fee, tests, Rx, supplies, other professional fees) Provider contract agreements Negotiated unit pricing Co-pays, deductibles, out-of-pocket Benchmarking Comparison to other providers in both cost and quality How should we present info? Easy to understand format Common language to describe price information Explain how and why prices vary Encourage patients to include price, quality and safety when making decisions Provide direction to obtain financial assistance information 20

21 Insured Factors There are different variables for an insured patient that may affect their payment including: Co-payments Co-insurance or Deductibles based on their policy benefits and coverage Out of Network providers Non-covered services Health Plans Insurers will have the most accurate prices for their members, they should serve as the primary source of price information for pricing information Most plans have web based pricing tools to allow members to understand their out of pocket cost for procedures Insured patients should have a clear understanding of their financial responsibility 21

22 Variables If a patient intentionally seeks care from an out of network provider the price will be higher and it will be their responsibility to get the price from the provider. If the hospital is in network but physicians giving care are out of network, the hospital should notify the patient to check with those physicians regarding price of services. In emergency care situations the patient should work with their insurance company to determine pricing. Uninsured Patients Accurate estimates of pricing should be provided listing the services that are included. Patients need to understand that unexpected care is not included in their estimate. Clarify that the patient may receive bills from other providers in addition to the hospital bill. Provide discount information that is available. Direct patients to information regarding financial assistance. 22

23 Pricing Considerations Inpatient Costs More difficult to determine due to inconsistent charging practices or supply usage. Care is not always the same for the same diagnosis due to other influencing health factors. Using average charges for the same DRG will allow you to give estimates that are at least in the ballpark of what a patient may owe. Determine cost to allow upfront staff to give close estimates of responsibility, especially for uninsured. Pricing Considerations Outpatient Costs Easier to determine outpatient ancillary service costs and pricing. Radiology, Laboratory, GI procedures should be consistent with accurate estimates available. Outpatient surgeries can be estimated utilizing average by procedure performed. Include implants in pricing estimates Both IP and OP should include information re: professional costs 23

24 Hospital Tools Defensible Fees/Charges Customer Focused Communication Patient Price Estimator Hospital Tools Data Analytics Web Based Payment System Other Web Based Solutions (Interactive) 24

25 Price Transparency Program No better time to start! 1. Establish a Price Transparency Committee 1. Include key financial and operational staff 2. Decide key characteristics to include: 1. Methods of info sharing (website, patient portal, Smart phone apps) 2. Price estimation software 3. Links to quality measures 3. Evaluate your current process No Easy Task Being transparent is not an easy task. Every patient has different variables affecting what they will have to pay. Insured and Uninsured will have different needs. We have to find ways to provide accurate information to all of our patients. Where do we start? 25

26 Chargemaster We have to start with the basics and the foundation of the hospital system, the Chargemaster. Poll Question Chargemaster A living, breathing document 26

27 What is a Chargemaster? A Chargemaster is also called a Charge Description Master It is a comprehensive listing of items billable to a hospital patient or a patient s insurance provider. It is a master file built within the hospital information system. It contains multiple data elements related to the charges that are assigned to items and services used or provided for a patient. Every item in the Chargemaster is assigned a set price used to generate bills. Why should it be maintained? 1. It drives hospital reimbursement 2. It provides data for reporting 3. It ensures financial and governmental compliance 4. It provides information for your cost reporting 5. It helps create clean claims 6. It is the most important communication tool between providers and payers 27

28 What if it isn t maintained? 1. Decreases cash flow 2. You are unable to do accurate data gathering/reporting 3. It makes you vulnerable to audits and penalties 4. You are unable to accurately report your costs 5. Increase claims edits which creates a backlog and decreases cash flow Learning Outcomes Identify why pricing transparency is important to consumers List the factors that a consumer may use to determine the value of a service. Identify ways to communicate and present pricing information to the consumer. List different variables that may affect pricing Describe the definition of a hospital Chargemaster. 28

29 NEXT STEPS COLLABORATION Who in your hospital would benefit from this series? Who should you share this information with? Do you have best practices that you can share with us? What do you need from your peers and other hospitals? 29

30 To Do List Determine who at your facility is responsible for maintaining your Chargemaster. Download your Chargemaster into an excel spreadsheet. Include: Item code Revenue code Description Department CPT/HCPCS code and any modifiers Charge amounts To Do List Sort by department Each department manager should be provided a copy of their department s Chargemaster Have each manager look over and get familiar with their Chargemaster All department managers should register to be on our next webinar 30

31 What s Next? (OCT 12, 2pm) Chargemaster basics Key data elements Revenue code descriptions and how they affect reimbursement CPT/HCPCS codes and why they are important to reimbursement Modifiers and how they communicate information to the payer Who is responsible for assigning codes to the claim Webinars 3 and 4 will be department specific What s Next? Our last webinar will be more on Price Transparency and will include information on developing your own program. If you have a Price Transparency program in place please share it with us!! 31

32 Poll Question CONSORTIUM SUPPORT: WEBSITE DASHBOARD IOWA GA/FL Contact us for password PROGRAM CALENDAR Cheat Sheet 32

33 Dashboard Instructions - Iowa Go To HTHU.net/iahtc Enter Your Password Scroll down to the 3 projects which require another password Dashboard Instructions - Iowa Below the 3 projects you will see: Consortium Projects Divided by Financial, Quality and Technology Click on the registration links for the series you would like to attend You only register once per series We will send you reminders 33

34 Dashboard Instructions - Iowa You also can access courses in the main HTHU site from your dashboard Any courses taken in the main HTHU require you to login If you have never registered you can do that here Once logged in click on buy to take the course Dashboard Instructions - Georgia Go To HTHU.net/htc17 Enter Password You will see resources, calendar and newsletters Consortium Projects Divided by Financial, Quality and Technology Click on the registration links for the series you would like to attend You only register once per series We will send you reminders 34

35 Questions? Questions about these resources or Upcoming Events? Contact: Sandy Sage, Financial Program Lead or Jennie Price, SHIP Program Manager TELL US HOW WE DID! A survey will launch after this webinar closes: please take a moment to give us your feedback on the training, speaker, content, webinar format, and anything else you can share! If there s something we can help your hospital with, please let us know! 35

36 References ntent/14transparency-taskfcreport.pdf ntent/14transparency-principles.pdf employer-health-benefits-survey/ 36