Emergency Room or Urgent Care?
What is a patient’s typical experience when seeking care? Oftentimes, patients determine the most appropriate action based on their symptoms, particularly when choosing to visit the emergency room or an urgent care for clinical services. Unfortunately, many patients are making the wrong choice when choosing where to seek care when they are ill. According to UCHealth, approximately 30 percent of patients who visit the emergency room should have visited an urgent care center for care.[1] Since the onset of the public health emergency caused by COVID-19, patients have been encouraged by hospital systems and rural hospitals to visit urgent care locations for medical care for symptoms and illnesses that are unrelated to COVID-19. Such action is because hospital administrators decided to post messages, alerts, and advice to patients informing them of the need to visit urgent care centers for non-emergent care and COVID-19 testing sites for testing and the administration of the vaccine in an attempt to ensure patients with emergent needs were appropriately cared for in their facilities.
Follow-Up Care Instructions Don’t Always Translate
When visiting an urgent care center or emergency room, patients should receive information related to the care they received to follow up with a primary physician or specialist. In terms of the clinical aspect, clinicians sometimes do not consider the percentage of information patients retain while visiting their site for clinical assistance. Per an article published in 2018 by Patient Data Access News, patients typically retain approximately 49 percent of the information providers give them without prompting, which could negatively impact the patient’s care and overall experience.[2] Patients typically are, or should be, provided with nonverbal information, such as a discharge summary, aftercare instructions and follow-up information related to the reason for the patient’s visit. In some cases, this does not occur and may be detrimental to the patient’s overall care.
Revenue Cycle Also Integral to Patient Experience
As healthcare providers responsible for the patient experience, we should not only consider the clinical aspect of patient care. According to an American College of Healthcare Executives (ACHE) white paper published in 2020, the top cause of denials has remained constant since 2016:
- Registration or eligibility accounted for nearly 30 percent of denial causes
- Authorization/pre-certification accounted for close to 15 percent
- Non-covered services resulted in nearly 11 percent of denials[3]
The patient’s experience includes the revenue cycle flow, beginning with scheduling and registration through billing and claim adjudication. Ensuring the patient’s demographic and insurance information is accurate includes eligibility. Over the last decade or more, the healthcare industry has observed several disputes with payors, which have resulted in a lack of patient care for some individuals. Oftentimes, patients will visit a clinical organization for care, provide their insurance information (which may be out of network due to unsuccessful contract negotiations), but are not notified of the out-of-network status. This could be due to a lack of training and job-aids or system-related challenges; however, the induvial who is most at risk is the patient, as they will more than likely be responsible for a balance of which they are unaware (a challenge that has been addressed by the Surprise Billing Act). These actions will likely result in a less than satisfactory patient experience, particularly for individuals who are not as familiar with healthcare best practices as those who work in the industry.
Factors Beyond Clinical That Make Up Patient Experience
Additional components of ensuring the patient has an exceptional experience include:
- Validating documentation and patient service times, as well as the appropriateness and accuracy of charges;
- Maintaining communication with the patient’s payor and the patient (in certain circumstances);
- Confirming that the patient’s record reflects the services received during the visit; and,
- Ensuring payments are applied timely, minimizing the possibility of patients receiving invoices reflecting incorrect patient responsibility and/or balances.
We’ve provided a patient experience journey map that displays a high-level view of the issues patients may encounter when receiving care, whether inpatient, emergency, ambulatory or urgent care, including clinical and revenue aspects. As shown, the patient’s experience began with a challenging experience based on the inaccuracies of the steps that were executed during the registration stage. The experience extended throughout the entire visit and billing. The patient received a bill with a patient responsibility that did not accurately reflect the services provided at the time of service. Unfortunately, the disadvantage to patients is due to a lack of awareness or misunderstanding of the processes that occur within healthcare that potentially render an adverse impact to patient care and financial responsibility. Therefore, it is the responsibility of healthcare providers to ensure that we are accurately and timely completing necessary tasks, including documenting care, processing patient demographic and payor information, documenting clinical services and submitting claims. Such actions are meant to proactively improve customer service and the patient experience.
Advocates for Patient Experience
Windham Brannon firmly believes that providers should view the patient’s experience from a patient-centric perspective, evaluating all areas that could potentially cause an adverse impact on the overall patient experience, including clinical care and revenue cycle processes. For more information, reach out to your Windham Brannon advisor, or contact Valerie Barckhoff and Danielle Epps.
[1] https://www.uchealth.org/services/emergency-care/when-should-i-go-to-the-emergency-room
[2] https://patientengagementhit.com/news/patient-recall-suffers-as-patients-remember-half-of-health-infoPatients
[3] https://www.ache.org/-/media/ache/about-ache/corporate-partners/the_change_healthcare_2020-revenue_cycle_denials_index.pdf