Managing the patient financial experience at UTMB is a group effort, consisting of cross-functional teams within our patient care areas and our financial clearance support. Most recently, this effort has been challenged by the new mandates around price transparency and providing estimated costs prior to service delivery; and the overall trend towards patients being savvier about healthcare costs while plans become savvier about complicating reimbursement.
Additionally, renewed focus on our cash collections has necessitated that we re-examine our workflows to ensure that all expected patient liability amounts are collected in full. This can happen pre-service, at arrival, or at the patient’s departure from the clinic. This is critical information to communicate as part of the patient’s experience, particularly in the context of same-day services. Determination of medical necessity and deferral of payment requirements is a necessary part of this collections process to ensure that appropriate clinical standards of care are followed.
Within our outpatient office visits, the associated possible treatment options can vary wildly between clinics and services. In Primary Care, we lean towards immediate ‘point of care’ interventions such as basic labs, plain films, and pathology swabs. In Specialty Care, treatment options may involve injections of high-cost drugs, biopsies, complicated lab panels, and other complex office procedures that require financial clearance. Additionally, patients may need post-visit advanced imaging or a referral to ancillary services, which is normally coordinated by the clinic staff based on communication received in Epic from the care team.
In some cases, the patients are scheduled to return for a procedure visit at a designated time or location that is appropriate for the provider and patient. In others, the treatment options are appropriate to be done as part of the evaluation and management of the patient on the same day.
In all cases, it is helpful to understand how the financial clearance process works for office activities. Depending on the patient’s financial information, treatment options may require special handling.
The effort to gauge probable treatment options prior to seeing the patient takes some collaboration between provider preferences, scheduling workflows, and billing data. But it can be done. For example, in primary care, patients with upper respiratory
symptoms can be presented with an estimate of possible or probable costs based on their signs and symptoms. This includes a chest x-ray, flu swab, covid swab, CBC, and other data-driven items we know are appropriate for the patient’s complaint.
While the patient is not charged for these items unless they are done, we are providing them with as much accurate information as possible to help them manage their out-of-pocket healthcare expenses.
On the other side of the Financial Experience are the “Payors,” the owners of the requirements for authorizations and approvals. In our upper respiratory example, we know that certain plans may require authorizations for the possible or probable treatment options already identified. That requires that we obtain authorization presumptively based on chief complaint, or within 24 hours after providing the service requiring authorization. If we miss the 24-hour deadline, the payors can deny payment for the service outright.
We expect a certain amount of revenue for the services we perform, but without accurate and timely authorizations we can expect delays and denials from the plans for any reimbursement. Additionally, a patient cannot always be held responsible for their portion of services denied for authorizations. This means without authorization; provider time and hospital resources are being provided for free.
A recommended best practice is for each clinical service to work with Revenue Cycle Operations to identify the most common and appropriate scenarios for clinic visits and procedures. This will help determine workflows to be implemented for predictive financial clearance options as well as swift ad-hoc validations as needed for medically urgent interventions. Proactive work within our cross-functional teams will benefit everyone and ensure a smoothly efficient process in the clinic. Agility within our cross-functional teams will allow us to quickly respond to urgent or emergent issues that fall outside of established workflows and processes.
Above all, our intent as an institution is to provide the best possible patient experience for our patients and the best possible user workflow experience for our providers and staff. Financial Clearance is a necessary part of this mission. As UTMB pursues innovation across all mission areas, the innovation of our registration and billing processes cannot be overlooked.
In the coming months, we will feature information about specific specialties, services, and initiatives around financial clearance for the physician and provider audience.
 | Revenue Cycle Financial Clearance is working in conjunction with Coding Education to bring you information to manage the patient experience for all patients at UTMB. We invite you to contact us to schedule large group, small group, or 1:1 training. We are dedicated to the education and success of all UTMB providers. Please contact the Revenue Cycle Coding Education Team to ask questions or schedule a meeting. We are here to help! Email the Coding Education Team. |