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Navigating Price Transparency Requirements

Part Three - Offering Patients a Self-Service Cost Estimate Tool


Launching the Cost Estimate Tool


Maintaining The Cost Estimate Tool


Continuing Patient Education

Previous: Two - Price Transparency in Ohio
Next: Four - Conclusion & Results


Transcribed Video Content Below

Launching the Tool

We're going to talk about the offerings of a self-service estimates tool. We’ll discuss some of the thought processes, philosophies and details around maintenance. As mentioned before, we really wanted to be able to commit to patient or community independence engagements and autonomy where the patient or community wanted autonomy.

Going to the "nuts and bolts" of this self-service estimator, it seems like it could be very easy. You just put your top payers, your top services out there and fly. It was really not that easy. With the financial literacy about it being built very complex, it just makes it even more complex in the self-service world.

Although we’ve had kiosks for patients, it typically has asked them information that they simply know, like their demographic or their insurance name, or what their co-pay is. But, they didn't really know all the jargon clinically, even if when an appointment is made, they knew they needed it, the doctor said they needed it, and therefore they scheduled the appointment.

When, as mentioned, we put out an RFP, we were looking for a partner that understood estimates; that understood insurance allowables. PMMC, being a national company, and being so well versed in it, we used them in the past for other types of contract modeling, patient estimate and insurance estimate information.

And they are just phenomenal, in not only being able to be flexible and agile, but being able to take all of that information from claims, from contracts, etc. Being able to bring that information into something meaningful that contract management can understand, our own departments and revenue cycle can understand, and also equate that to what a patient can understand in reference to estimates.

And so, when we were reviewing and doing the selection, we not only looked at that expertise, but we were also looking at somebody who would partner with us to be able to come up with a patient portal that appeared to be simple and was transparent. That people would not have to understand the complexities behind it, and that is why PMMC was awarded that contract. Because of the proven history they had with us, and the ability not only to leverage technology but to tailor it to specific to our needs and our population.

We also worked with our communication group, our web department group, and also our IT, so that when we were approaching our patient advocacy groups, we could bring with them alternatives and choices so that they all had a thumbprint on what we were developing together. We needed to have an easy feel and touch. We needed to know how much information to put on the website, but also be concise enough so that the patients and community would get the answers that they were looking for and not have so much information that they would be discouraged. I, for one, if I can't do something on a website that I can get in a couple of minutes or less, I typically get discouraged and I pick up a phone call, which was not the purpose of this patient self-serve web portal.

Our pre-service teams are very skilled in what we've done before, so they have first-hand knowledge also of all the questions they got asked regarding estimates, and where we needed to integrate with financial coordination etc. So we knew it wasn't just about providing an estimate, but we also had to have the web portal engaging enough so that we would be able to provide outreach and financial education to the consumer. And make sure that even the uninsured and underinsured could use this website and reach out to people to help them with understanding what the cost would be specific to them. So that’s a pretty big group of diverse individuals that we needed to reach out to.


Next, we're going to discuss the technical aspects and then also talk about what our thought process was when we were going through the technical aspects.

So basically, I gave you kind of a generality of what we were doing. Some of the stuff is really doing your data mining. What are your top diagnoses and procedures that are being asked about? Not necessarily what your top diagnoses and procedures are in reference to what the hospital and your providers are providing.

And it was a very interesting discussion because we used PMMC also for our Chargemaster and for contract modeling. And quickly, we found that for the CDM and for contract modeling, what was considered the top for them, certainly was not the top for the patient estimates.

We had those discussions, which was one of the lessons learned, to be honest with you, because I think people were thinking that they would bring in the same information as it went to payers and diagnoses and it did not. So that brought some very healthy discussions between both teams and the result was really through PMMC and us, is that we really need to keep it in sync but where to start with our priorities.

So of course, we started our priority about what the patients want to see. I mentioned that we needed to be simple. I mentioned that we needed to have common language before. We wanted to make sure that we were always confirming an estimate. So although in our estimator we provided information, we made sure that we were disclosing that it was an estimate and that we would confirm something in writing if they were more interested in it. You could see that we added 14 payer contracts, and we also added 34 procedures within 12 specialties to get started with.

Generating an Estimate

Basically, I'm from Missouri. I like to see it happening and the bottom line is this is our landing page and this just came out with the button at the bottom which says "my cost estimator," highlighted in yellow. Although we launched this in July, our web folks were not ready. They had an emergency project, and so, but “my cost estimator” ended up being on the landing page, but it was buried in a listing of all kind of activity and functions that our patients could access under financial assistance program.


And we knew we wanted it on the landing page because there are three things that patients always ask about:

  • •   "How do I pay my bills?"
  • •   “How do I get financial assistance, which could be assistance with getting insurance or the HCE program”
  • •   “What is it going to cost me?"

So you'll see later, I'll explain why it's so important on the landing page to have that estimator right their forefront when a patient opens up your website. And then on page 19, you're going to hear me say this a lot, the disclaimer is essential. And we did have a disclaimer prior. We used something very similar for the web estimator. We did have our legal department review the disclaimer.

We did not want to discourage people from using the estimate because, as you know, when you're getting pre-cert from insurance, they always have a disclaimer, "Well, we're giving you an authorization number but we're not guaranteeing payment." And we didn't want patients to have that kind of an attitude, but we did want them to understand, and you can see it in the middle "final determination," is really critical. So we wanted our patients to understand, we're giving you this information, but you should not stop here. So this is extremely critical and we did, and it's extremely critical with the verbiage which our Patient Focus Group agreed with it also.


And this is really where I'm going to basically say PMMC flourished and the entire team of people in managing this project with us. Based on our community and based on the literacy of people as it relates to understanding insurance etc., we felt, I am a school teacher also, or was a school teacher, people learn differently. People learn by reading, people learn audio through conversation, and people learn through visual. And it was very important to us to have visuals. It was all very important to be able to filter so that the patients wouldn't have to filter through things that would not even be applicable to them. Again, we didn't want to discourage the patient.

So basically, this was put in and initially we said, "Well, let's just put in a figure," and then of course I said, "Well, let's do a figure of a male and a female." So the PMMC team was very, very patient, very collaborative and they brainstormed with us. So the fact that we put a male and female, and visually you could select the part of the body, automatically that started to filter the information in the service category. So that we would not have female services when you sort on the male, or male services when you sort it on a female.

So that was the one automatic filtering that we were able to get very, very quickly. Now, for the example we've provided colonoscopy, but you can see below all the services, categories that we were actually listing. The word “service” was used because the word “specialty” was very confusing to people. And also, there could be services that primary care provides, like vaccines. And so in the world of healthcare, that's not considered a "specialty," it's considered primary care. So that's kind of the thought process we were going through in reference to even the visual and just the service category.


We had some additional discussions about which services to provide and, again, we took our claims and we ran them by CPT code and DRG, from top to bottom of utilization by each payer, actually, and, because that can also differ of course. And then we have some payers that bring in more volume than others. It was very specific only to the category of CPT codes to DRG, but also to the category of our payers.

And so, this basically gives you the services that we looked at. And I can tell you if you go down a little bit, we're asking for copay and coinsurance, which again, took many, many meetings of conversation. The first one, where you see my professional services. In Ohio we have many labor groups, teachers, for instance, who have what we call split coverage. Their professional coverage is different than their technical coverage. Now, for our hospital, my department actually is responsible for both professional billing and hospital billing. So for us our estimator has to represent both sides of the fence.

For others that may not be true. So our first thing was to be able to provide guidance, so that if they did have split coverage they'd be able to put it here what their co-pays were in coinsurance for both professional and technical. The second question that says, that they either know they're deductible, and out-of-pocket, that is important because some patients know their deductible right that minute. We're only going to know their deductible based on whether or not we look at it, but another claim could come in and two minutes later that could change.

So we give patients the option to give us as much information as possible. We actually did have on here a selector for max benefits. However, when we looked at our patient population with our payers, max benefits was not something that was really common and we thought it may cause more questions than that, even if we had a hovered help over it where those question marks represent what we’re asking for the patients. So we took max benefit right off of it.

Again, we didn't want people to say, "I don't know that," and leave our website. So the next one is being able to actually get the estimate. I already did that, but anyways the service benefits I just actually explained… and I just wanted to point out here, even though we ask for this, if a patient is uninsured, then what happens is, when they hit co-pay, they actually have a pop-up that tells them what the next step is, so that you can see the uninsured patients. And this is actually showing up, also, all the insurances that we have loaded today. And we have a list of about 25 more that we're going to be loading within the next three to four weeks.

So then finally you can finally go to the next page. Because you pressed “Get my estimate” and you get a full estimate. Now this is a very simple estimate, but you can see that under co-pay amount, we actually show the total but we show what the hospital is and what the professional is. Same thing with coinsurance amount, if there’s a hospital in the professional and if the patient gives us a deductible and what the responsibility of the patient is.

And again, we're providing that this is the best estimate to remind the patient in case they forgot. They have the capability to print the estimate, and this is what they would see printed. And they also have the ability to reach out to our patients, to our pre-service center. What we are not showing here is the screen for our uninsured patients, but there actually is a screen that tells our uninsured patients what they can actually look at and talk to us.

And if you go to page 24, you’re going to see what they actually receive. And the reason we do this is because we do not want patients to become concerned if they’re seeing an out-of-pocket expense that they cannot afford and we encourage them to contact us. Now, we have a very rich financial assistance program for the uninsured, and so if they are uninsured and they're already on that program, they're aware of it, where you see the MetroHealth financial assistance program.

If they've never been through that program, then we give them another number so that we can work with them and make a determination if there's, again, HCE, Medicaid, other governmental programs, or one of our financial assistance programs that we can get them involved.

And we don't charge anyone full-charge. We have an algorithm based on where the uninsured and underinsured are seeing, if it's trauma unit or burn unit, if it comes through our Life Sight Program, and or based on their actual level of income. And if a person truly is 100% self-pay and they don't qualify for what people would traditionally think is a financial assistance program, we still do provide a discount so that the full charges are not billed to our patients.


So basically, we service everybody and the estimator is to engage the patient and be able to talk to them. One of the things I wanted to mention on the screen, also, is we had a lot of conversation, "Do we require patients, even with insurance, to give us our demographics etc.?" We do not, that was a philosophical decision. That part of our philosophy was to give people autonomy, allow them to shop. Eventually we may set up comparison-shopping right on our website. So we did not want to require people filling out demographics or filling out an email address or a phone.

We give them that as an option if they choose to do it, once they print their estimate, but not as a requirement because that would go against the philosophy of opening up this web portal to everyone regardless as to whether they want to contact us or not. We can manage how many times it's opened etc., but we do rely on the patient to let us know if they want to contact us.

Maintaining the Estimate Tool

We have it [the ‘My Cost Estimator’ set up in-house to maintain it. And as I mentioned, we just launched it in July. So we are going to be adding additional payers and services. However we needed somebody to control this and manage it and to collaborate with PMMC. There are a lot of things that we could do on our own, like add additional diagnosis, additional services, additional categories, additional procedures.

But we also collaborate with PMMC in reference to the actual payers because they are literally loading our contracts for us so that not only are we updating our CDM with them on a regular basis, we're able to get our contract loads if there's any changes or any new contracts. So we have combination of our estimates based on claims history and also based on our specific contracts.


So we engaged Julie Merrick, who is our pre-service manager, who works under Phyllis Cleary, who's our director of Patient Access and Enrollment. And she really works with her team in reference to responses from patients etc., and what we're seeing on the web portal, and also our other estimates that we provide in order to keep updating this portal.

Our web group, our communications group, and our IT group are very impressed by how easy it is to collaborate with PMMC when we need their involvement and a quick turnaround, as well as how quickly they can update, or even Julie, herself can do the updates without having an IT background in the areas that we need those updates to take place.

Continuing Patient Education

Continuing with patient education – just because this is out there doesn't mean that patients are going to use it and then just leave; they're going to call us. We are very proud that our estimates are extremely close, and I'll explain that again a little bit later. But when we're talking to the patient and we're giving estimates, we make sure that it's more robust than the dollars, and what I mean by that is a simple mammogram could have one out-of-pocket expense.

However, between breast density and tunnel thesis and other services that maybe provided, we do let the patient know that there is the potential that there could be other charges. And often times the patient then will share with us that they do have a situation where they believe they need bone density, or breast density, and then from there, we are able to give them other information.

A second example of that is cost for delivery. We always want to have a healthy baby. But there's challenges sometimes where the baby may not be healthy. So when they're asking for information in reference to deliveries, basically what happens is we will also have the discussion that this is referring to a healthy baby, and if there's any challenges that they may already be aware of, we would be able to give them some estimates as it relates to that. And we actually do do that.

So basically, those are examples so that we can expound upon estimates. Not that the estimate itself may not be close, but rather that there could be other circumstances that we would need to discuss.

Another example would be potentially an implant. If it's just a shopper, we could give them a full estimate. But when they reach out to us, we like to tell them once they have a discussion with their doctor to please let us re-confirm the estimate incase, for some reason, there was a decision that the implant that was chosen for let's say somebody 68 years old, was an implant for knee replacement, for somebody less active. But this person was a professional tennis player and needed a knee implant that would last longer and take more endurance. Those are the kinds of discussions that we have once we engage with the patient.

Poll Question and Q&A Session

We'll pause here to have another question and answer session. We’ll also share the results from our previous in-conference poll. And as a reminder, that question was, "Does the organization offer a self-service patient cost estimator online?"

  • •   18% of attendees said “Yes”
  • •   64% said “No”
  • •   18% said they plan to do so within 12 months

Our final poll for the day asks, "Will your organization be changing price transparency efforts within the next 12 months in response to state legislation?" The answers here are, yes, no and uncertain. Our first audience question comes from Pamela and she would like to know,

Q: Do you collect on those estimates while providing them over the phone?

A: Yes, we do. In fact, that's extremely important because that also gives the opportunity when we talk to the patient to collect in full. It opens up the communication as to whether or not that patient has the capability of collecting in full, and if we believe that there is a propensity to pay, but not the capacity to pay, then that's when we move into a deposit possible payment arrangement. If we find that even with that there may be a Medicare patient who doesn't have any secondary insurance that moves us into that financial coordination. So we collect as much as we can, and also we do collect all of it right away, but it also provides a expectation for both us and the patient, if it cannot be collected immediately.

Q: Our next question comes from Pamela, who asks, "What registration or billing system are you using?"

A: We use Epic.

Q: Not all patients are tech savvy, so who handles the patients that are not able to do the tech self-services, and do they then get a letter, a verbal estimate, or both?

A: It is a pre-service department. As I said, we've been doing estimates for over 10 years, and so patients, or even the community, if they go to our website, there's always been a listing of the contact of our service area. Or they ask a provider, if they ask, there are operators, or any of the departments, everybody knows to reach out with our phone number and give it to patients. So that can be done by telephone with no problem. And then what we always do is follow up with a confirmation letter with that patient.

We have a lot of Spanish-speaking individuals, so we can ask the patient would they have a preference, and we will have someone on the phone speak with them. In reference to the estimate and then send out, currently a letter estimate out in Spanish if we need to. And then, also, because we have individuals who speak other languages, we ask their preference and we have a translator line for immediate assistance with that.

Q: Great. Our Next question comes from Ann, and it might be more for the PMMC folks on the line. She wants to know how easily this set up could be modified for another hospital or health system.

A: Yes, good afternoon. This is Terry McManus with PMMC. It's actually very easy to set up for anybody who currently has our Estimator Pro product. The framework for generating the self-portal is already built within the system.

Q: Thank you. Our last question for this session and then we'll move on, comes from Kim. Kim asks, "Do you roll all charges up under main CPT such as supplies, pharmacy, and hourly charges, or do you list them separately on the estimate?"

A: On the estimate, what we basically do is we have this even for our statements, is on the hospital side, we have created user-friendly revenue codes, if you will. So we have roll-ups in that sense. If somebody is interested in more itemizations, we can provide that because of the fact of using claim history in addition to the contract. So we will have those separated. We also would have anesthesiologist separated so that the patients clearly can define what the providers are and what type of providers from implants, and supplies, and that type of thing.

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