Shifting the Payment Culture and Processes: Viewing People Without Insurance as Valuable Customers

New Haven, CT

ContextFor over 40 years as a private, 501 (C) 3, non-profit

organization the APT Foundation has successfully provided services to individuals with substance use and mental health disorders in our community. Most staff have never worked anywhere else.

The Foundation offers a variety of services including, out-patient treatment, medication assisted treatment, group treatment, individual therapy, primary care, vocational services, and residential care. The programs have historically operated fairly independently from one another.

Since 2007, a key emphasis has been on access, and the company has grown from about 13M in size to about 20M by 2010.

Revenue Picture•For decades, the organization was heavily

reliant on grant dollars from the State of CT which represented approximately 60% of revenues in 2006.

•Most other revenues were Medicaid or SAGA (general assistance) – 30%.

•First party clients represented about 10% of revenues, and were often discharged from treatment for failure to pay.

Growth Strategies and Values•Time to treatment was a barrier to

admission and reducing time became key to welcoming clients, but sometimes challenged the culture of organization.

•Financial screening was a barrier to timely admission – moving the screening process to after admission was key to improving census and admitting all persons in need – regardless of ability to pay.

Waiting Days to Admission – APT Foundation

APT Foundation - Outpatient Census

APT Foundation in Deliberate Growth Mode – Access Matters

FY 2009 FY 2010

Evaluations 2642 2937

Admission 1955 2092

Total Census (All Programs)

2729 3276

Despite difficult financial challenges (loss of approximately $1.6M/year in FY 10 revenue due to State of CT budget recessions) we continued to grow services to all clients, regardless of payment status, in the belief that persons in recovery become more responsible over time and theorizing that an open door would position APT as the “go-to” provider in the community. A MAJOR OPPORTUNITY

1. AIM (Plan) – Accelerating Reform Initiative – January 2010•Improve 1st Party collections (people

who pay out of pocket – our major opportunity)

•Proactively manage the entire revenue cycle (i.e. bill and collect for services delivered, with constant data informing the process)

•Improve 3rd Party Authorizations

Back to the Basics – A Walk Through•To get started thinking about the payment

process for first party clients, we did a walk-through. Our biggest surprise – After a person was assessed a fee on our sliding scale, he/she was never asked for payment again! Payment issues were only discussed if the client became delinquent, and then often resulted in a discharge from care.

First Party Goals – The Changes (Do) Took financial management out of the back room • Created a practice manager position –staffed with

a person that has both a business and clinical background – added that person to the senior management and operations management teams.

• Inserted a friendly payment request into the check-in process “Are you prepared to make a payment today?”

• Educated clinicians regarding client finances as a clinical issue and engaged them to problem solve with clients around financial issues

• Met with clients and offered amnesty from past due balances. Wrote off about $120,000 in 3 mths.

3. Results – 1st Party CollectionsAverage 1st Party collections

▫ Weekly cash increase of 85%▫ Annual cash increase: $510,952

Third Party Authorizations – The Changes (DO)• Established a team approach to collections;

engaged clinicians in collections process as opposed to only to the business managers

• Created a revenue cycle team to oversee a circular process vs. a linear process

• Wide sharing of data regarding authorizations and collection, both for first party and third party clients

It Takes A Village…

IT Staff

A/R Staff

Practice Management

Front Door Staff

APT Foundation Leadership

3. Results – 3rd Party Collections

▫ 3% improvement in billed amount▫ 5% improvement in collected amount ▫ $402,187 annual revenue increase

4. Next Steps•Conduct a review of 1st party clients to

look for opportunities for increased collections as a result of health care reform and state of CT Medicaid changes (i.e. 18-20 year olds will now be covered under Medicaid)

•Staff will assist clients in application process

•Regular staff discussion around increased opportunity for Medicaid benefits and other emerging coverage options.

5. Impact• Clients reported feeling more engaged and secure • Collection process is not punitive so clients come

forward to discuss financial issues as they are coached in recovery skills

• Continued decrease in grant revenue as the primary revenue source (from 60% to 35%)

• Multi-disciplinary cohesion around financial issues and patient care

• Improved financial performance and improved census

Systems Driven Behavior“most managers get into trouble because they forget to think in circles. I mean this literally. Managerial problems persist because managers continue to believe that there are such things as unilateral causation, independent and dependent variables, origins and terminations”.

Karl Weick, The Social Psychology of Organization, 1979

Acknowledgements/Contact Info•Thanks to the many APT Foundation staff

who shifted their roles and continue to work toward customer friendly approaches to business processes.

•Lynn Madden and Michele Bissell can be reached at the APT Foundation, 203-781-4600.