Urgent message: Changes to insurance plan design are resulting in increased financial exposure for patients, with urgent care providers scrambling to adapt to the associated rise in patient consumerism. It therefore behooves the urgent care provider to evolve their financial systems and policies such that they align with emerging point-of-sale best practices in order to meet patient expectations, enhance the revenue cycle, and cultivate patient loyalty.
Alan A. Ayers, MBA, MAcc is Chief Executive Officer of Velocity Urgent Care, LLC and is Practice Management Editor of The Journal of Urgent Care Medicine.
As the number of healthcare patients with high-deductible health plans (HDHPs) has grown tremendously over the past decade, patient consumerism has grown right along with it. Responsible for larger and larger portions of their healthcare bill, patient expectations have definitely shifted. No longer passive recipients of their healthcare, today’s patients demand competitive pricing and all the other hallmarks of a traditional consumer marketplace: convenience, access, high quality, and a frictionless financial transaction.
In addition to burgeoning consumerism, a secondary (and corelated) consequence of proliferating HDHPs is the creation of a larger class of patients who are underinsured. These “underinsured” patients (ie, having coverage plans with low monthly premiums but high deductibles) face high out-of-pocket costs relative to their incomes, causing them to weigh their point-of-care decisions carefully. And when they decide a medical visit or procedure doesn’t make sense for them financially, they’ll react in one of several ways: delay or forgo care, not pay their share of the bill, self-diagnose and/or treat with over-the-counter medications, or bypass their HDHP and pay out-of-pocket.
How Underinsured Urgent Care Patients Behave
Underscoring the issue, a frequent observation in urgent care centers is an increase in the number of patients with insurance who choose to pay cash instead. Front-office staffers consistently see patients who are listed with one insurance in the system come into the clinic, tell the receptionist they’re uninsured, and request to pay cash.
Cash-pay used to be for the uninsured but, again, the landscape has shifted. Since enactment of the Affordable Care Act, technically, nobody should really be “uninsured,” but increased cost sharing and rising deductibles can make healthcare cost-prohibitive. As such, this encourages some covered patients to behave as if they’re uninsured regardless. For the urgent care’s part, when servicing a patient whose insured by an in-network carrier, they’re required by the insurance contract to take the patient’s copay and bill the insurance. An urgent care cannot, however, force a patient to use their insurance.
These “covered but cash pay” patients are savvy consumers who understand they have a HDHP—making them responsible for the cost of their entire visit—and that their total cost will likely be lower if they go ahead and pay out-of-pocket at the time of service. In effect, they’re playing the financial long game. But the urgent care “charge master” of prices typically isn’t disclosed to the public, so how are patients determining that an out-of-pocket cash payment would ultimately be less expensive? Through either experience, or an understanding of the way their coverage works.
When an urgent care operator bills insurance, for instance, it is common to charge an elevated rate (typically, 200%-300% of Medicare), knowing that the insurance company will adjust the bill down to the contracted amount. If an insurance contract pays, say, $165, the urgent care may bill insurance $200 to assure it receives the highest allowable reimbursement and no money gets left on the table. Any amount not reimbursed by insurance can be written off. Additionally, some urgent care centers add billable codes correlated to night/weekend or walk-in availability, which may or may not be reimbursed by insurance and frequently get written off.
So, if the patient wound up responsible for the bill, they could be charged the entire billable amount or the insurance-contracted amount, either of which might be higher than if the patient had paid cash. Smart patients with HDHPs that leave them underinsured understand this and are increasingly opting to pay cash at the time of service.
The Revenue Cycle and the Patient Financial Journey
In short, the proliferation of HDHPs has helped create a significant number of both underinsured cash-pay patients, and financially distressed patients who forgo care altogether. While the two can often overlap, when taken together they prevent both a challenge and an opportunity for healthcare providers.
For the cash-pay patient steeped in the tenets of health care consumerism, convenience is king. As they shoulder a greater share of their healthcare financial burden, they demand easy access, financial transparency, and a frictionless financial transaction—and have demonstrated the willingness to shop providers until they find one that delivers.
For those who forgo care due to perceiving it to be unaffordable, patient advocacy and financial counseling become paramount. When this patient fully understands their bill, their financial obligations, and their payment options, and their questions and fears are addressed at each juncture, their loyalty and resulting healthcare spend can be recaptured. Even patients with adequate insurance coverage are empowered in this consumerism-driven era, and demand similar levels of improved quality, value, transparency, and convenient financial transactions.
As mentioned, these patient groups can be one and the same; instead of a clear line of delineation between them, they frequently overlap depending on the situation. Regardless, the urgent care revenue cycle, particularly at the point of sale, must be better optimized to serve patients at each point of their financial journey. From preregistration through billing and payment, postvisit, and collections, payment mechanisms, technology, and policies must be implemented to elevate the financial experience, bring these patients back into the fold, and engender long-term loyalty to the provider.
With that in mind, the following sections will spotlight current best practices in the areas of convenience, access, transparency, and ease of the financial transaction, and offer suggestions and strategies for carrying them out in your urgent care center. We’ll also take a brief look at the Portland, OR-based Zoom+Care urgent care operation, and how its systems and policies are allowing the chain to flourish in a consumer-driven healthcare market.
Today’s consumer has grown accustomed to leveraging technology and tools to access products and services when they need them, where they need them. They reserve restaurant seats, order meals ahead of time, request grocery delivery, and arrange transportation (eg, Uber, Lyft) through apps on their phone. In short, they interact with these service providers on their own terms, in ways that fits their schedule and lifestyle. And as healthcare patients who embrace consumerism, they expect providers to deliver the same level of access and convenience. Hence, an urgent care center that seeks to capitalize on patients’ desire for convenience should implement the following technologies:
- Online queueing system – This technology allows patients to “reserve” their spot online, and shift their waiting location from in the clinic lobby to their car while they run errands, or even the comfort of their own home. Patients would be able to reserve their spot from any web-enabled device and receive text alerts for time estimates for when it’s their turn to see the physician, or if any unexpected delays occur. While this convenience isn’t the same as an actual appointment, it does allow the patient to wait on their own terms the same way they do with restaurant call-ahead seating and other services.
- E-registration/preregistration system – After reserving their spot online, patients should also have an option to register their demographics and medical/social history online. This feature saves them the inconvenience of having to fill out a clipboard or tablet in the lobby or exam room, which allows them to speed up their visit. It also gives the patient an opportunity to look over their information to ensure that it’s accurate ahead of the visit, avoiding potential delays and registration errors that could lead to a claim denial.
- Online patient portal – Urgent care centers should invest in full-featured online patient portal technology to afford patients’ around-the-clock remote access to their personal health information. This technology also serves to shift some administrative tasks away from front office staffers, freeing up valuable time to focus on in-person patient care. A secure password-protected portal should provide the following features and access to patients:
- Two-way private messaging with the provider and/or urgent care staff for health questions and concerns
- The ability to view personal and private health records, patient history, and view/print their chart
- Labs, test results, and their medication list
- Refill requests
- Follow-up appointment scheduling and upcoming appointment reminders
- Email and text notifications
- Marketing-focused push notifications (eg, sports physical promotions, flu shots)
- Online patient bill pay – Today’s patient should have an easy, convenient way to pay their medical bills from their mobile device, either in-clinic or at home. Investing in an online payment solution where patients can access their account balance information and submit a secure credit card payment helps to streamline the payment process and significantly bolster collections.
Point-of-Sale Financial Best Practices
The financial behaviors of the growing pool of HDHP patients can negatively affect financial outcomes of providers across the healthcare landscape. As noted earlier, cash-strapped patients concerned that they can’t afford treatment may forgo it altogether, whereas other patients who are confused about their financial obligations, face surprise charges, or experience frustrations about how and when to pay are likely to experience high levels of dissatisfaction. Urgent care providers, therefore, must closely examine their patient-facing revenue cycle operations and strive to put systems and mechanisms in place toward making the financial experience positive and seamless, which patients are increasingly demanding. These include:
- Price transparency – The first principle in elevating the financial experience is eliminating price uncertainty. Consider: what other competitive service industry has the kind of baked-in price uncertainty that has plagued healthcare for decades? Few, if any. Urgent care providers who lag here must therefore move to ensure that their clinic features full price transparency for all services and procedures, which can then be compared by the patient with other urgent care providers. To that end, there should be a large menu board with posted pricing in the lobby, and price listings on your website, social media channels, and any other viable touchpoints. Additionally, there should never be any surprise charges after the visit.
- Frictionless financial transaction – The point-of-sale urgent care financial transaction must evolve from its current state, with several fragmented processes, to an integrated, comprehensive system that eliminates friction and results in a seamless financial transaction, ending with payment for service being collected. In urgent care, the financial transaction entails confirming the patient’s information, verifying insurance, identifying any deductibles/copays/co-insurance or other patient responsibility, notifying the patient of prospective balances due, and collecting payment. The point-of-sale financial process should also entail registration quality assurance. This would involve staff members verifying that the information entered on each other’s computer systems is correct, ; this can be performed during lulls or slow periods. Such a redundant system of checks and balances to ensure that patient information is correct up front can prevent hassles and payment delay errors on the back end.
- Financial counseling/advocacy – The role of the front desk today has become much more complex than simply “medical receptionist.” Indeed, the front desk function must now include financial counseling, which is crucial for helping patients understand the benefits provided by their employer or the government, what services they can afford through either their insurance or out-of-pocket, and the options they have for paying their bill.
- Credit card preauthorization – When a patient’s financial obligation cannot be definitively ascertained at the time of service, the practice of credit card preauthorization can be an effective safety net. The process begins with the urgent care operation swiping the patient’s credit card, then placing an authorization on the account for the anticipated charge of the visit. Once the patient signs off to approve the authorization, the medical visit proceeds after which the patient is notified by email of the calculated charges. Finally, the patient’s card is either charged within 7 days, or the authorization is released when insurance is verified.
- Clear, consolidated billing – Rather than create separate bills for imaging, labs, etc. there should be one consolidated bill for all services during the visit. Additionally, the billing statement should be created in a way that makes it easy for the patient to understand the charges and to pay it in a single transaction. Financial counseling should be available at any point where there is confusion about a charge or service, or an explanation of insurer benefits is necessary. It cannot be understated how important a touchpoint the billing and collections process is in cultivating patient satisfaction and loyalty. Frustrated and confused patients will look for another provider, while happy patients will return.
Zoom+Care: A Brief Look at a Thriving, Consumerism-Based Urgent Care Model
Dating all the way back to 2006, the Zoom+Care urgent care operation in Portland, OR has been at the forefront insofar as meeting the demands of patient consumerism. Implementation of mobile technology throughout the platform, online scheduling, telemedicine, and flat and transparent pricing are among the patient-centered features that has allowed Zoom+Care to thrive and serve as an exemplary example of the kind of “outside the box” innovation that’s possible in the urgent care space. Here, we take a brief look at the way the model leverages technology, policies, and payment mechanisms toward excellent patient service.
Zoom+Care (35 locations) breaks the day down into 15 minute “appointments” which patients book online. A credit card is required to schedule one of these appointments, and if a patient cancels with less than a 1-hour notice, their card gets charged $99. Because of this practice, Zoom+Care does not accept Medicare, Medicaid, or Tricare. The advantage of this practice is it smooths the ebb and flow of a walk-in clinic by pacing arrivals in 15-minute increments. It also optimizes productivity of the providers and staff and facilitates diversion to nearby locations if a clinic is particularly busy. Patients who know exactly when the provider will be available to see them have greater control over their wait, vs being “stuck” in a waiting room.
Additionally, Zoom+Care has a “safety net” payment policy: If your insurance company isn’t able to verify your benefits, the clinic collects the total cost at the time of your visit and issues a refund once they receive payment from your insurance company (typically, within 30 to 45 business days). This policy saves the company money, as it’s far less expensive to issue refunds on credit card charges than to pursue unpaid accounts through collections, which often results in write-offs.
Additionally, Zoom+Care has a comprehensive price list posted in-clinic and online, with one flat cash price of $165 for an injury or illness visit (medications and lab tests extra).
Unlike urgent care centers who sometimes try to “jury-rig” an insurance fee schedule for cash patients (including offering 25%─-35% prompt-pay discounts on rates that are not transparent to patients), there are no surprises for Zoom+Care patients. Zoom+Care’s pricing is also consistent with the trend towards insurance “case rate” or flat-fee payment from insurance, regardless of services performed. The downside is they may be leaving money on the table for higher-reimbursing procedures (such as suturing or ortho cases, for example).
Lastly, Zoom+Care does not accept cash or checks. A debit or credit card is required to make a reservation and payment. Going cashless greatly helps operationally as Zoom+Care staff don’t have to worry about the hassles associated with cash handling, safes, change kitty, daily bank runs…and it’s a trend that more and more retail businesses seem to be embracing.
As patients increasingly bear the brunt of financial responsibility for their own healthcare costs, they’ll continue to embrace the tenets of consumerism. This puts the onus on healthcare providers to adapt their service models such that convenience, access, and frictionless financial transactions are no longer regarded as a perk, but rather an integral part of the business model. Today’s patients—accustomed to high quality and value through their other service providers —demand nothing less and are voting with their pocketbooks to prove it.
Urgent care, therefore, must grasp the enormous revenue opportunity in aligning with policies, procedures, and mechanisms that elevate the patient financial experience, and embrace them wholeheartedly at every point in the patient’s financial journey. Doing so will allow urgent care providers to better compete in an ever-growing market, meet consumer demands, and capture long-term patient loyalty.