Price transparency has become increasingly important part of the patient financial experience, particularly as patients are becoming smarter healthcare consumers.
Deborah Vancleave, vice president of revenue cycle at St. Joseph, Mo.-based Mosaic Life Care, knows this, given her background, and she knows the challenges related to providing this transparency.
Ms. Vancleave has more than 20 years of experience in revenue cycle management, consulting, administrative management, financial management, customer service, sales/marketing and technology in healthcare.
She stepped into her current role at Mosaic in 2016.
Before joining Mosaic, she was senior director of client performance at Conifer Health Solutions, part of Dallas-based Tenet Healthcare.
Here, Ms. Vancleave shares her biggest challenges related to price transparency, discusses Mosaic's price transparency efforts and offers advice for other hospital revenue cycle leaders.
Editor's note: Responses were lightly edited for length and clarity.
Question: What is the biggest challenge related to healthcare price transparency?
Deborah Vancleave: For Mosaic, the biggest challenge related to healthcare price transparency is an increasingly difficult and complex process to gather information from payers for things such as reimbursement, patient out-of-pocket costs and prior authorizations. Payers have long refused to guarantee any reimbursement amounts. They will tell providers that they must adjudicate the claim before they know how the claim will be paid. Some payer contracts still pay providers a percentage of allowed charges, where some will provide a fee schedule for basic reimbursement. To add even more complexity, most large payers have a multitude of health plan products which all reimburse the provider at different rates for the same services.
Another significant challenge to the accurate calculation of the patient estimation is the fluidity of deductibles, plus applicable coinsurances. Coinsurance amounts are calculated based on the "allowed amount" and are dictated per the patient's health plan product. The coinsurance liability can also vary greatly dependent on the type of service provided or if it is in-network vs. out of network. Ultimately, it is a significant challenge for providers to produce accurate pricing without an accurate "allowed amount" from the insurance payers prior to claim adjudication and comprehensive patient-specific benefit information returned in the electronic eligibility response. This leaves us with generalizations and quoting reimbursement averages.
Q: How is Mosaic Life Care working to address this challenge?
DV: Mosaic Life Care is dedicated to providing our patients with the most information possible, so they are confident in the care they receive and the price they pay. Since 2017, Mosaic has made significant efforts to improve the patient financial experience. We began working on pricing transparency long before any [federal] mandates.
The internal changes have been strenuous, but well worth it for our patients. We implemented back-end eligibility, estimation and quality assurance software. We have created two financial clearance units and have implemented a new patient-facing price estimation tool, Estimate My Cost. To increase transparency, we are also participating in the Missouri Hospital Association's project to deliver cost and quality data from our inpatient and emergency hospital services. This gives patients access to data that shows how Mosaic compares to other healthcare organizations and state averages in terms of pricing, outcomes and quality of care.
Concurrently, we are working to enhance our patient-facing price estimator by merging with our current web portal to offer patients choices of physicians and specialists along with quality ratings. We also have plans to tie online price estimation to the patient payment portal, which would allow for better adherence to the estimated costs and create greater opportunity for patients to secure payment arrangements or interest-free financing prior to service.
Q: Have these efforts been successful? How so?
DV: First and foremost, we are compliant in regard to pricing transparency. I am skeptical that transparency efforts will have a positive impact on the cost of healthcare overall. However, providing estimates to patients in advance of medical services is essential. Because we have been patient-focused, we have been very successful with our insight and ability to forecast the need as well as the pending regulations. However, the actual implementations and changes to our structure and processes takes time.
Q: What is your advice for other hospitals looking to improve price transparency?
DV: Leverage advancements in technology and put more pressure on your payers to communicate out-of-pocket costs to their members.
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