Reducing Preventive Flips to Diagnostic— A Holistic Approach to Improving the Financial Experience for Members


Peter Gazanian; Erin Bilvado, MBA

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Colorado, Georgia, Hawaii, Mid-Atlantic States, Northern California, Northwest, Southern California, Washington, Program Office

Background: Rising medical costs are in the national spotlight and have been a growing concern for our members. Kaiser Permanente (KP) surveys show 50% of members are surprised by bills they receive. Contact centers report more than 20% of service billing complaints are a result of visits scheduled as preventive, then billed as diagnostic. Members are reaching out for help, even to the office of Bernard J Tyson. Improving our members’ financial experience is of utmost importance as we transform internal operations to uphold the KP mission of providing affordable health care.
Methods: The study targeted preventive encounters that commonly result in surprise diagnostic charges and member complaints. Member complaints are identified through the financial service recovery program, which provides a stopgap by empowering contact center representatives to resolve issues and, if appropriate, adjust charges within set guardrails. On the basis of the documented reasons for complaints, cross-functional teams, including Patient Financial Services, Permanente Medical Groups, Revenue Cycle, and Benefits, review accounts and conduct data analysis to determine key root causes and options for resolution of the issues. The initial focus is reducing negative experiences and member complaints around preventive examinations.
Results: Analysis of complaints received for scheduled preventive visits billed as diagnostic revealed 70% were indeed preventive examinations. In the KP California Regions, 3.4 million preventive examinations occurred in 2018 with 617,000 visits (18%) resulting in additional patient cost share. Of the 617,000 visits, 16% resulted in members reaching out to the contact center with 9% resolved through an adjustment of charges and 1% through a formal grievance. Analysis of these member complaints revealed 2 major scenarios: 1) cases where preventive services were documented and system alignment could potentially resolve the issue, and 2) cases where nonpreventive services were present.
Discussion: Solutions to the complex issues in our organization and industry will not be determined or designed while staying within the silos of our departments or functions. We must work together—holistically and iteratively—with shared accountability to achieve a truly integrated care and coverage experience that has our members at the center. As next steps, priority opportunities are being identified and driven to address the preventive examination issue under executive leadership across Patient Financial Services, Permanente Medical Groups, Revenue Cycle, and Benefits. Additional improvement efforts are in the queue, including vision and laboratory services.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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