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Jeff Lin
Host of Payment Matters
Payment Matters is a monthly radio show focusing on real issues happening in healthcare payments. Jeff chats with industry experts and thought leaders to bring fresh perspectives on how providers, payers and consumers are all tackling the evolving healthcare payments market. Join the conversation on Twitter with #PaymentMatters.

In this episode, Jeff speaks with revenue cycle consultant, Carolyn Rubin, about engaging consumers in the billing and payments process.

Jeff Lin: Today, we have the privilege of talking about consumer engagement in the billing and payment process. I’m joined by my guest, Carolyn Rubin, who is a revenue cycle consultant. Carolyn, thank you for joining us today. Can you tell us a little bit about yourself, and your experiences?

Carolyn Rubin: Thank you, Jeff. It’s wonderful to be here. I have been in the healthcare field for 25 years. I’ve been a revenue cycle consultant the majority of that time, working with physician groups, then hospital groups on everything from the time the patient makes their appointment until the time the claim is paid, helping them with end-to-end revenue cycle optimization.

Jeff Lin: You’ve seen the industry change through the years, from the way providers get paid to how they work with patients. What is your perspective on how the changes in patient responsibility have altered how providers view the patient or how the patient views the provider?

Carolyn Rubin: Yeah, there have been a lot of changes over the years. It used to be easy for the patients. They could just call their physician, make an appointment, go in and maybe have a co-pay that was $5 or $10, but most of the time not. They’d go in to see their physician, have done whatever needed to be done and go on home. They didn’t have to worry about referrals. They didn’t have to worry about authorizations. They didn’t have to worry about the physician being in-network or out-of-network or whether the procedure was covered, or not covered, based on their diagnosis. Was it cosmetic or not cosmetic? Things have changed so much over the last 10 years, and even more so in the last two or three years.

Patients don’t understand what their insurance benefits are and the physician offices, even the hospitals, struggle to explain the benefits to patients. Maybe there’s an authorization that’s required, and the insurance company may deny it based on their benefits. Or it’s because of how the employer structured their insurance and opted not to cover something. Or maybe the patient went with a lower premium with their employer and they chose the higher deductible. Or they ended up with a coverage that didn’t cover a particular service.

It’s very tough for patients now. When they decide to have a service covered, they may call and find out that the physician that they’ve been seeing for the last five years has decided to no longer take their insurance, because of the reimbursement that particular payer was offering. Providers struggle with how to have that conversation with the patient and explain that to them. It’s an ongoing challenge for both the providers and the patient to figure out.

Jeff Lin: That’s interesting. It’s very complex. The patients are confused by their benefits. They’re walking into the providers who, as you mentioned, they’ve been seeing for the past five years and all of a sudden, is no longer accepting their insurance. Or they have no idea what their benefits mean. That they’re denied to get that reimbursed. In the tri-party relationship, by which I mean the provider, the patient and the payer, have you seen anything in terms of how providers are engaging with patients and helping them understand the benefits or their plan? Have you seen anything being done that can reduce the confusion tied to benefits?

Carolyn Rubin: I wish I could say yes. In most cases, no. The individuals that are working to explain to the patient what their benefits are, are just as confused as the patients. When they’re calling the insurance company to try to figure out what the patient’s coverage is, sometimes they’re not asking the right questions. Or they’re asking the same questions that they asked yesterday or last year, only to find out when they submit the claim that they should have asked that question a little bit differently.

For example, the patient may have been getting an injection or a particular medication whenever they went to their physician’s office, and they’ve been getting that injection for their particular illness monthly for the last two years. It’s always been paid at the physician’s office. Then the patient’s plan changed, and now that coverage is underneath their pharmacy benefit versus their medical benefit. But when the staff verified the insurance, they didn’t ask about the particular codes or the particular medications or the particular services that that patient was receiving. All they asked was if the patients still had benefits, if they still had coverage and what their out-of-pocket or co-pay was. The staff got the same information, but they didn’t ask about the specific services. Now all of a sudden, the claim is denied, and they’re having to explain to the patient that their benefits are no longer the same. That the patient now has to get this drug from the pharmacy, or they have to go through a specialty pharmacy to get that prescription filled, and it’s now a higher out-of-pocket cost.

If the staff doesn’t know what questions to ask or if they’re not asking the right questions at the physician’s office, then they’re not getting the right information for the patient. It’s just as confusing and it’s just as complex, and it all is because the staff at the physician’s office need the education and understanding to know that benefits have changed or that there are different questions that need to be asked.

Jeff Lin: It’s almost as if the relationship between the patient and provider has changed. They need to be working closer together to understand what’s covered, what’s not covered and the payments that are going to be happening. Have you seen that relationship get better, worse or stay the same over the past five, ten years?

Carolyn Rubin: It stays the same in some aspects, because of the confusion. It gets a little better in some aspects, if they have a true advocate at that provider’s office that they can talk to, that truly understands what’s going on. Many times, the patient has to go back to their HR person or their employer to ask why something isn’t covered anymore. The physician’s office has to ask that patient what their benefits are now. It’s getting that patient involved more to understand what their insurance is doing.

In the past, when patients signed up for insurance, they would understand they had a co-pay, they went to a certain pharmacy and that their medications were a specific cost. Now, they don’t have quite the understanding of what their employer benefits are. They just expect to be able to go to the doctor or to the pharmacy.

There’s so much that’s going on. And there are so many changes happening at every payer level whether it’s Medicare, the Medicare Advantage Plans, Blue Cross, the Cignas or the United Health Cares. There are so many changes that are taking place that it’s tough for the staff at a physician’s office to keep track of all of that. However, if they sit down and take the time to talk to that patient and to look at that information, they can help that patient understand.

Because of all the changes that are taking place on the regulatory side, when we talk about HIPAA and patient privacy, including where and how you can have those conversations, a lot of the challenge is actually having the conversation while not delaying the patient from their appointment. They’re typically trying to get them back to see the physician, and the patient wants to get back to see their physician, so you’re trying not to delay the appointment. The patient might be scared to have the conversation, because they don’t have the money to pay that high deductible and they don’t know what their options are. The person at the front desk may have only been there for a week, two weeks, maybe even a month, and they’ve not had the type of training needed to have the type of conversation they need to have.

That’s kind of a convoluted and complex answer to go with a complex situation. It really all comes down to the fact that as things get more complex within the industry, it is also more complex to educate the staff to have the type of conversation that they need to have with the patient because there are just too many changes. Too many options and too many variables that come into play.

Jeff Lin: Yeah, it’s very complex and I wish there was a magic bullet to solve everything. You mentioned before that co-pays used to be the norm. Twenty dollars might be all you would pay. I remember, back in those days, that you wouldn’t get a bill. All you would pay is the co-pay. But now, high deductibles are more in vogue.

We previously had another guest whose comment was that the last impression is the lasting impression. At the end of the day, there are clearly some struggles with payments, the billing process, all that stuff that needs to occur with the patient, how to communicate with them and the payment process. What have you seen in terms of those struggles, especially with how complex it is to understand these bills? What are your experiences tied to billing the patient and collecting those payments?

Carolyn Rubin: Even yesterday, I was having a conversation with an individual who was going through this, the same frustration. She had to have some tests run at a hospital. She went in to have an MRI and a CT scan and some other tests completed. She saw her physician first who said that she needed to have this done, this done and this done. She said, OK. She went to each of the departments to have her tests completed. In each one of them, when she got there, they said, OK, we’ll get you in to have your MRI done. I need $350, because that’s your out of pocket. She was like, OK. And then she went to have her CT scan done, and before they would do the CT scan, they were like, it’s $1,700 that I need today for you to have your CT scan. That’s what it’s come down to.

It used to be that you would go in to have your procedures completed. The provider would submit everything to insurance, you would get the statement and you would pay whatever your out-of-pocket was. Or you could call and set up payment arrangements, and you could take care of it at that point in time. The problem that we have today, is that the high deductible plans that everybody is on are very high deductible plans. Most of the deductibles on these plans that patients are signing up for are $3,000, $6,000, $10,000. The ACA plans, the Affordable Care Act plans, some of those start out at $7,500 or higher. These patients, they don’t have that. They’re getting the bills in the mail and they’re pitching them. They’re sending them right on to the trashcan. They’re not even opening that mail.

And so, it’s trying to figure out how you can actually communicate with the patient, give them the options and help them understand what is available to them before you actually send a statement out. The easiest way to do that is to engage that patient from the very beginning. It’s not just saying, you owe me $1,700, it’s helping them understand what their benefits are and the available options. Showing the patient how you can take care of this for them and making it easy for them. Open up some online portals. Be able to save their card on file. Be able to put a payment plan in place that you know they’re going to be able to capture every single month.

When you look at consumer payments today, whether it’s healthcare or a car payment or a house payment, everybody has payments that they’re making. And let’s not even look at a house payment or a car payment. Everyone has cell phones today. Everyone is watching TV of some sort, whether they’re watching Netflix or they have cable TV or they have satellite. We all have those different options, and it’s sitting down and having that conversation with the patient to see what options are best for them.

If you talk to them, in that direction, and engage the patient to figure out what works for them, you’ll have a very successful conversation, and it’ll make it easy for that patient. But they need to know what their options are. If you just say to them, I need $1,700, they’re going to look at you and say, Yeah, well, that’s not going to happen because I have a house payment. I have a car payment. I have groceries I need to buy. I need to do this; I need to do that. What’s going to end up taking place is that the patient is not going have that test done, or they’re not going to make that doctor’s appointment or they’re not going to get that medication filled.

We need to truly engage the patient. Connect with the patient, through the right type of conversation. We need to educate the patient to the different types of options that are available. For every single provider’s office that I have worked with, and that I have talked to, that is where their struggle is. Having that patient engagement, and having that true, connecting conversation where they can lay it out and help that patient understand that the provider is not there to wipe out their checkbook. They’re truly there to educate them on what’s available.

Jeff Lin: What would you say to those providers that say they’re too busy? That they can’t be focused on this additional activity of educating and working through these payment options. What would be your response to them?

Carolyn Rubin: The first thing I tell the providers that I work with is to quit telling patients not to worry about it. Because patients will pour their hearts out to physicians. And the physicians, they don’t want to worry about finances. I don’t want physicians to get involved, to be quite honest. I don’t want physicians to get involved in that because the first thing physicians do is say, Oh, don’t worry about it. I’ll talk to Susie at the front desk, and we’ll take care of it. You just need to worry about getting better. When the physician does that, the first thing the patient thinks is, Oh, I don’t have to pay anything.

I tell the physicians to quit telling the patients that. What I want physicians to do, and what I always tell my physicians that I’m working with to do, is to let the patients know that you’ll look at their benefits, and you have multiple options available for them. You will provide them with the best quality financial care, as well as provide them with the best quality medical care. You’re going to make sure that they can focus on getting better, but they need to work with Susie at the front desk on the insurance, and work with you on whatever is needed to do medically to get better. Between you and Susie, you’ll get the patient there.

I need the physicians to acknowledge that things have changed in healthcare. And the physicians are getting it. When they hear it from their financial people, they understand that they can no longer say to patients, Don’t worry about it. Because if they do that, they will no longer get the reimbursement. They’ll no longer get the revenue for their services because nine times out of 10, patients have the high deductibles and the high out-of-pockets, which means everything that they’re doing for that patient is not getting paid unless this patient pays their bill.

It’s very important that physicians understand that they need to support Susie having the time to sit down and educate the patient about what their benefits are and what benefits are available to help. What payment plans are available. What services are available for that patient. It may be that the patient qualifies for financial assistance, or maybe a program that they have available, even internally within their own organization. But they have to support that.

As I’m going in and talking to different organizations, it may mean that they need to hire an additional financial advisor in order to have the right number of people to have those conversations. But it pays for itself. At the end of the year, the ROI, the return on investment, of having that additional financial advisor to spend time with the patient is well worth it, because you get the dollars in the door. Whereas before, if the physician was saying, Oh, don’t worry about it. I don’t want you to stress over it. And then the patients just never pay anything, it becomes bad debt. Bad debt doesn’t pay salaries. It’s patients paying their bills that pays the salaries.

I need physicians to actually support their staff having the conversations with the patients. I want physicians to let the patients know that they’re going to receive both quality financial care and quality medical care while they’re there at that office. Whatever help they need, they’re going to get, because they’ve got the best people to make sure that that happens.

Jeff Lin: That’s some great feedback. I’ve heard the old adage, which is, people, process and technology, right? You need those three things in order to, in effect, impact change. As I think about our discussion today, technology, offering payment options, online portals, payment plans, doing things in an automated fashion…they’re not going to save the day. You have to get people on board. Actually talk to them, and put processes in place to get charity assistance or other kind of care.

You focused on ROI. It’s tough to tell someone to go hire more people to do more things, even if there’s a pretty good chance that they’ll make up that money, if not more, by doing that. Do you have any anecdotes or financial insights you can share where by taking specific action, an organization could reduce debt or increase collections by a certain amount? Have you seen any real examples of measurable metrics or horror stories that can shine a light on what can be done if healthcare organizations take on those activities that you alluded to earlier?

Carolyn Rubin: I’ve seen both. I’ve seen horror stories, and I’ve seen great results come about. You were talking about technology. So many times I’ll hear individuals say, Technology? Patients hate it. They don’t like going out there and using technology. They don’t want another login. They’ve got all of this they have to do now because we have to make them use the patient portal.

What I have found is that patients actually will do it if you make it easy for them. And the staff will do it if you give them the right tools, and it’s something that is beneficial for both the staff and the patient and it makes sense for everyone to do.

Jeff Lin: That’s great. Carolyn, thank you so much for your insights today. I learned quite a bit about how providers, patients and payments have changed over the years.

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