Empower Your Patients' Financial Experience (ePFX)

The revenue cycle is long and complicated. It contains many handoffs and potential timing delays which can impact the processes and technology that are further downstream. The complaints and challenges described by patients often have a root cause that occurs long before a patient receives or makes a phone call to a healthcare provider’s customer service call center.

Status and Processing of Balance After Insurance (BAI) Accounts

BAI accounts often have some of the highest reimbursement rates for the patient balance that remains after the insurance portion of the claim has been resolved. These balances are typically deductibles, co-pays, and co-insurance amounts. Patients with BAI balances are often anticipating that they will have a balance that they will owe following the resolution of their insurance. Insurance companies send the patient Explanation of Benefit (EOB) documents that confirm the insurance company’s understanding of the patient’s liability or balance.

We have found patient satisfaction is negatively impacted if we receive a placement of an account that shows as a Balance After Insurance, but there are no adjustments or payments from the insurance payer.

Why it’s Important

It stands to reason that a patient who has insurance has a certain expectation that their insurance is going to make a payment and the patient is only going to owe a deductible, co-pay, or co-insurance. BAI accounts that are placed with us that do not have an adjustment or placement typically mean that the amount being billed to the patient equates to the full charges or some amount much higher than the patient is expecting.

Hence, the patient is immediately upset to receive a bill that is well beyond the amount they were expecting. These patients often place calls to the hospital’s customer call center to inquire about the balance they have been billed and are typically upset to receive such a large bill.

These types of accounts usually point to a problem with the individual account, with the processing of accounts for this insurance payer or a system problem in processing third party insurance accounts.

Identifying the root cause of insurance accounts being processed without payment is important to prevent future patients from encountering the same type of issue. Also, these types of accounts can create challenges for providers and their insurance companies.

We have found that patients not only make a call to the provider, but also to the insurance company. If the provider is not appropriately processing the bills associated with insurance companies or an individual insurance company, the insurance company might take note of these challenges and use them as leverage during contract rate negotiations or use this information when developing their provider networks.

Age of Account at Time of Assignment

The age of accounts when they are placed with an early out or bad debt partner has a significant impact on patient satisfaction. We have found that the older an account has aged from discharge or last charge date, the more negative an impact is felt in patient satisfaction.

When accounts are placed with an early out or bad debt partner, typically the first action taken by the partner is to mail or electronically send a statement to the patient. If this statement is 6 months, a year, or multiple years following the services provided, patients tend to become very frustrated and upset. Receiving an untimely statement says to the patient that the hospitals process and systems are broken. No one enjoys the surprise of finding a bill in the mail they were not expecting.

Why it’s Important

Aged accounts placed with early-out or bad debt vendors typically indicate that there was either an issue in processing this account or there is a more systemic issue with the processing of accounts. As each step in the revenue cycle is related to the previous and subsequent steps, there are many places where the process or technology can break down. Here are a few potential root causes of where these breakdowns might occur:

1. Issues with the initial collection of data during the registration / admissions process
2. Inability to generate a bill or patient statement
3. Challenges with the processing of insurance accounts
4. Problems with generating placement files for early out / bad debt partners
5. Manual or automated holds placed on individual or groups of accounts

Communication between a provider and their early-out / bad debt partners can help to identify these accounts where accounts appear to be aged prior to placement. Early discovery of these accounts is important to the timely identification and resolution of root causes creating placement timing issues.

Amount of Patient Liability

We have found that the amount owed by a patient can affect the patient’s satisfaction with the provider. Based on analysis of the 100,000 patient satisfaction surveys, there is a correlation between rising account balances and declining patient satisfaction scores. The more we owe, the unhappier we tend to be.

Why it’s Important

The amount owed by a patient has many drivers. One patient might owe more than another patient due to the differences in the services received, their insurance coverage (or lack thereof), processing of the insurance portion of their bill, whether or not the provider was in or out of network, and so on.

Our statistical research has found that previous account demographics and statistics are a good predictor of future account performance. For example, providers that performs certain services or are located in communities with certain socio-economic dynamics tend to drive patient account balances. If a provider performs high cost or elective procedures, they often have patient balances that are higher. If a provider registers more patients without insurance or with insurance that has higher deductibles or co-pays, patients’ balances are often higher. We have found that additional education to patients, communicated prior to service regarding the liabilities they will owe, helps to mitigate the negative patient satisfaction with receiving a high dollar bill.

Timeliness of Payments on Accounts

Similar to the items described above, the timeliness of processing accounts has a significant impact on patient satisfaction. We have found that patient satisfaction declines when the initial payment on an account is delayed. The first payment could be from an insurance payer or a patient. It’s not the type of payment that drives the patient satisfaction impact, but rather the timeliness of any payment. When payments are delayed, it often implies an issue with the clean processing of accounts through the revenue cycle.

Why it’s Important

This indicator is important because it again speaks to the timeliness of processing accounts through the revenue cycle. If the first payment on an account is aged beyond comparative well performing revenue cycles or similar accounts within the accounts receivable of a single provider, it typically points to issues within the billing, claims processing, or account migration through a business office. Delays in initial payment often mean that an insurance company’s payment is late due to processing or denials or the patient has postponed paying on their account. When patients delay paying, it is often because they do not agree with the amount they owe or they are unable to pay. Either way, this has a negative impact on the provider’s cash flow and timely processing of accounts receivable.

For many patients, the last contact they will have with a provider related to their healthcare experience is in their dealings with the provider’s customer call center. The Patient Financial Experience delivered by the provider’s customer call center is often the determining factor in the patient’s overall satisfaction and perception of the provider. As the last point of contact, the customer call center can heavily impact a patient’s loyalty to a healthcare provider. The call center’s interaction with a patient while following up on a $500 deductible can protect or put at risk millions of dollars of revenue related to that patient and their family.

Volume of Accounts Routing to Bad Debt

Healthcare providers and their early out partners typically agree on a communication campaign they will follow for each patient account. For example, a common communication campaign for early out partners is to send a series of three or four patient statements and to place two to three calls to a patient over the course of several months. If the outcome of that call campaign is that a patient cannot be contacted or the patient is unable to pay/refuses to pay, that patient account is typically sent to a bad debt collection agency to further pursue resolution of the patient’s liability.

We have found that where a healthcare provider has a higher percentage of accounts transitioning from early out to bad debt, the provider’s patient satisfaction scores tend to decline. This business intelligence tells us that providers who are sending more patients to bad debt collections as a percentage of their overall patient liabilities tend to have lower patient satisfaction scores.

Why it’s Important

A higher volume of accounts transitioning to bad debt is often an indicator of processing issues in the revenue cycle, a challenging payer mix for the provider, or community socio-economic trends that drive higher bad debt. While some of these items might be out of the control of the provider, it is important to understand the root cause and impact of higher percentages of accounts transitioning to bad debt.

With higher bad debt percentages, we encourage providers to revisit their charitable care policies and patient discount policies. By updating these policies, we have found that providers can demonstrate they are delivering additional community benefit through their charitable write-offs or help their early out vendor to collect additional monies through the use of aggress discounting strategies. After all, in the case of patient liability collections, sometimes collecting some money is better than collecting no money at all.

Volume of inbound calls to placed accounts

Early out and bad debt partners can often predict the volume of inbound calls based on the volume and type of patient statements sent to patients. We have found that some of our healthcare provider partners drive higher volumes of inbound calls. This is in comparison to competitors or similar healthcare. Our data scientists have demonstrated that higher percentages of patient calls have a negative impact on patient satisfaction. As more patients call in for a specific provider, that provider’s patient satisfaction scores tend to dip in direct proportion to the percentage and volume of inbound calls received.

Why it’s Important

Higher volumes of inbound calls from patients typically indicates that patients have questions about their bill or they disagree with the information contained on the bill or statement. Once again, the root cause of these patient calls can be from processing issues further upstream in the revenue cycle, patient statements that are not patient-friendly in their design, or a host of other root causes.

We encourage our partners to work with us to better understand the root causes of why patients are calling in and to look for account indicators that seem to be driving patient inquiries. For example, do more patients with a particular insurance coverage call more frequently or are patients that received specific services more likely to call. Over time, we have transitioned from manual tracking tools to more automated call root cause calls. These automation tools are delivered through speech analytics capabilities. More on speech analytics below.

Call Center Performance Metrics

Performance metrics within a call center can also be key indicators of patient satisfaction. Patients who wait on hold for extended periods of time, who are placed on hold during a call, or have extended overall call times tend to have lower patient satisfaction scores. While we have often assumed that certain call center performance metrics were indicators of patient satisfaction, we now have the empirical evidence to show the correlation between call center key performance indicators (KPIs) and patient satisfaction.

Why it’s Important

No one likes to place a call into a customer service call center and end up waiting on hold. It is important for call centers to be transparent with their partners in sharing performance statistics. These statistics can indicate staffing issues within the call center, increased volumes in calls, balancing challenges amongst call center teams, call center technology challenges, and a host of other potential call center improvement opportunities.

Volume of Returned Accounts

Similar to the description above of accounts transitioning from early out to bad debt, another common disposition of accounts is when the early out partner has to return the account from the partner’s inventory back to the healthcare provider’s inventory. Accounts are returned to a healthcare provider from an early out partner because they were placed in error, there is an error on the account that needs to be resolved and the early out partner cannot resolve the account issue, and host of other reasons. As a higher percentage of accounts is returned from the early out partner to the healthcare provider, we have seen a reduction in patient satisfaction scores.

Why it’s Important

As more accounts are returned to the healthcare provider, it typically indicates that there is either a data or processing issue with the account. As the percentage of accounts continues to grow, we have found that there is a greater likelihood of systemic processing issues with the healthcare provider. As more systemic issues are discovered, patients are more likely to receive erroneous information on statements or statements that have timing challenges – ultimately resulting in patient satisfaction declines.

The latest technology enhancement driving changes through the Patient Financial Experience is the introduction of Speech Analytics. For early-out and bad debt partners, speech analytics provides tools to analyze and scrutinize every word of every call. Where quality assurance programs were once very manual and covered a small percentage of calls conducted by call center staff, speech analytics provides us the opportunity to review every call, without subjectivity, and consistently across a full population of team members and calls.

In addition, speech analytics identify and score specific speech triggers spoken by patients. This includes individual words and phrases of words. This also includes the ability to analyze word phrases in context of the call. For example, did the patient indicate that they are calling on this issue for the first time or that they are calling regarding this issue on multiple occasions? Did the call center team member demonstrate empathy? As it is only possible to show empathy if a patient has spoken words of discontent or dissatisfaction, speech analytics can only recognize empathy as it follows specific words or phrases spoken by a patient.

Speech analytics provides customer call centers with the first opportunity really score the Patient Financial Experience. With a Patient Financial Experience score (ePFXscore) we are able to identify areas of opportunity to deliver a better Patient Financial Experience, protect current and future provider revenue, and address any customer call recovery issues in real time.

How Speech Analytics Work

For every recorded call, the speech analytics tool automatically creates a call transcript. We anticipate this year that we will record and transcribe over 150,000 hours of calls. This will include over 1.5 billion words.

Once the calls are transcribed, we use artificial intelligence tools to apply hundreds of rules against each word and phrase in every call. With those rules, we can confirm the appropriate phrases and actions are performed by call center staff and we can monitor the patient’s discussion to identify negative or concerning interactions. In addition to transcribed calls, we can process any other written communication through the rules engine – tweets, emails, surveys, letters, etc.

By comparing the speech analytics triggers and scores to over 100,000 patient satisfaction surveys, we have identified specific triggers and scores that tend to have the greatest impact on the patient satisfaction surveys. For the first time in healthcare, we can provide feedback on how the patient feels about the healthcare provider and their Patient Financial Experience.

As Maya Angelou stated, “I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” We can now provide feedback on how our healthcare provider partners and our team members in the call centers are making patients feel.

Specific Speech Analytics Triggers and Scoring [Negative Speech Analytics Triggers]

As described above, speech analytics provide the ability to apply rules to each spoken word and phrase included in calls placed or received by customer call centers. This also includes the ability to apply these rules to any written communication to or from patients. Our speech analytics tools automatically create a transcription of each call. As the calls are recorded in stereo, with the patient recorded in one channel and the patient service representative recorded in a separate channel, we can easily apply rules to either the patient or representative or to both.

As we’ve compared the various speech analytics rules to over 100,000 patient satisfaction surveys, we have identified a series of triggers that correlate with reduced patient satisfaction. If any of the following speech analytics rules are triggered, our data scientists have been able to identify a significant reduction in patient satisfaction. Of all of the criteria identified to negatively impact patient satisfaction, the triggering of these speech analytics triggers has the most significant impact on patient satisfaction. As a result of these statistical findings, we tend to weight the impact of these speech analytics greater that the other ePFXscore criteria.

Speech analytics triggers demonstrating the most significant impact on patient satisfaction:

1. Call Emotion
2. Agitation
3. Dissatisfaction
4. Escalation
5. Legal Action Mentions
6. Profanity
7. Risk & Abusive Language

Why it’s Important

The introduction of speech analytics marks a substantial leap forward in our ability to monitor and improve the Patient Financial Experience. Previously, a negative call center interaction was difficult for management to find and address. It often required a patient services representative to contact their manager and identify that a call had just gone poorly. Many patient services representatives might be hesitant to do so as they would know their performance on that call would be heavily scrutinized.

Another way to identify calls that have performed poorly is a result of receiving a complaint or escalation from the patient. Invariably, whenever a patient complains to the healthcare provider’s leadership team, all calls are retrieved and reviewed. Lastly, some negative calls might be discovered through the archaic quality assurance process of randomly sampling and reviewing calls.

Speech analytics provides an opportunity to review all calls, all phrases and all words spoken. Not only does this automate the identification of calls where a patient has had a negative experience, it also facilitates an opportunity to implement customer service recovery protocols and to predict those patients who are most likely to escalate.

Speech Analytics Indicating Patient Will Not Pay

Speech analytics can be utilized to identify very specific words or phrases spoken by patients during their interaction with patient services representatives. We have identified that the specific words and phrases spoken when the patient will not pay has a significantly negative impact on the patient’s financial experience.

A patient cannot or will not pay for any number of reasons, but we have found that when a patient speaks words indicating they will not pay, those accounts have disproportionally lower patient satisfaction survey scores..

Why it’s Important

Utilizing speech analytics to identify patients who will not pay is important for several reasons. A patient sharing their objection to pay or inability to pay provides for further research and discovery related to "why?" These root causes can identify issues with individual accounts or more systemic issues across the revenue cycle. We can utilize manual tracking and additional speech analytics rules to diagnose the root cause of why a patient cannot or will not pay.

For example:

• Is the patient sharing that they do not have the ability to pay?
• Is the patient challenging the amount owed?
• Is the patient challenging if they owe the full amount?
• Is the patient sharing concerns with their clinical care or some other issue that occurred during their interaction or services with the healthcare provider?
• Is the patient sharing that they don’t understand something about their bill or what they owe?

The identification of the root cause is the first step in resolving the patient’s challenges and obtaining payment. This may also help move the account to the next step in the revenue cycle process. For example, should the account be forward from early out to bad debt collections? This provides the healthcare provider an opportunity to assess and decide if the patient will receive additional statements, phone calls, or other communications.

The challenge with patient satisfaction surveys is that they provide a false sense of completeness and comprehensive feedback. We have found that less than 6% of callers to our call centers complete a patient satisfaction survey and the survey feedback we do receive tends to be skewed toward the polar ends of the feedback spectrum – it was the best or worst experience ever.

No one would argue that the understanding and calculation of patient satisfaction is an inexact science. No two patient financial experiences or expectations are exactly alike. Relying on HCAHPS Surveys that measure the clinical engagement lend little in data, often reflecting the best and worst service spectrum and completion rates of HCAHPS surveys nationwide pale at less than 30%. Post-call surveys also net limited results. Less than 1 out of 20 financial surveys are commonly completed. That often leaves you measuring your patient satisfaction based on net patient revenue or gut instinct. None of which are adequate indicators alone.

To the patient who’s being asked for money, it probably doesn’t really matter much if the person they’re speaking with is a brand new entry-level hire with a high school diploma making $10 an hour or a hospital leader making a six-figure income with an MBA. What really matters most is whether the employee is an active listener.

If we try to recall a customer service experience where we were really listened to, it might actually be difficult to come up with one. Imagine a world in which that kind of experience came from revenue cycle employees—not just the single best employee in the department who everyone raves about, but routinely from all employees. People would come to expect it from the hospital, wouldn’t they? And those would be loyal customers of the hospital for life, because active listening is that compelling for people. And training is how we make that happen.

Honestly, it takes a lot of effort to be an active listener, but the effort pays off in some surprising ways. Take a typical escalated call. If the caller is interrupted, challenged, or cut off, it’s a safe bet that person will complain vehemently to a hospital leader or elsewhere. We coach revenue cycle employees to actively listen instead. By allowing the caller to vent, it’s possible to ascertain what exactly he or she is upset over. It might be that a high-interest loan is their biggest concern. If that’s what the employee hears the irate caller saying, that’s important information because now the employee has something to offer the patient-- a zero-interest payment plan might just turn things around. Or it could be something else—every patient is different, of course-- which is where active listening becomes such a powerful tool.

Anyone who thinks talking about money isn’t personal never tried to collect from a patient. In our ePFXcoach training, we show employees how to tailor their approach to an individual’s personality. If the person seems open to chatting, that’s exactly what the employee does. Engaging conversations can takes the edge off of the serious subject matter for some people. On the other hand, if the person is all business, a direct approach is best. The employee gets right to the point, and simply explains the financial facts in a professional manner. We’ve seen time and again that this personalized approach can avoid friction that leads to escalation. Avoid the frustration that comes from using a “one size fits all” approach to financial conversations.

We avoid what we call “zero” words and instead use “hero” words. Time and again, we’ve seen the power of positive words. Instead of stating, “You can’t pay $10 a month because that’s not enough to meet our criteria,” employees state, “What I can do today is set you up on a $25 payment plan with absolutely no interest paid by you.” There are many other examples, but it’s undeniable that some words just trigger a negative reaction. Other words communicate a “can do” attitude that sends a positive message: We are here to help you.

A friendly tone of voice won’t be soon forgotten, and it’s impossible to overstate the importance of simply being kind. But no matter how nice the employee is, he or she has got to know the financials. Any caller, regardless of the amount owed, is going to appreciate someone who’s taken the trouble to do their homework before talking about money owed. Whether it’s a $50 copay or tens of thousands in liability, no one should be collecting from a patient if they can’t justify the amount in an easy-to- understand way that’s beyond reproach. Certainty and confidence is something patients will detect immediately. And those patients are more likely to pay their liability.

Imagine having to attempt to collect money from someone who is cursing at you, crying while on the phone or firing a series of panicked questions at you. That’s all in a day’s work for a revenue cycle employee. Conversations are unpredictable and yet they have common ground. They can be prepared for and practiced, just as any challenging conversation. And the more you practice, the better you get. S cripting that sounds robotic satisfies no one. The art is to interject one’s personality into the scripting for a natural conversation. That is the beauty of role playing, which allows employees to practice responses. If they hit a wrong note, some coaching and suggestions helps them to gain confidence. They can succeed with conversations in the “real world” where it really counts.

Satisfied patients who are being asked for money? It might seem like the impossible. But we can and do equip revenue cycle employees to give world-class service. And once they really get it—we see that employees put the skills to use eagerly. It’s as though they always wanted to give excellent service—nobody likes to get complaints-- but just didn’t have the tools to do it. The training has a domino effect on the employee and the revenue cycle, giving both some new life. The employee is now enthusiastic about coming to work. The customers have no reason to escalate. The revenue cycle is a source not of complaints, but of satisfaction.