Episode 65: Let’s Talk About the Bill

Most providers prefer to leave billing to someone else, but preparing for those awkward conversations can have a profound effect on the patient experience. In this episode, you’ll hear what providers should be communicating about billing, how to avoid common billing pitfalls, and simple ways to train your staff to address patient concerns early. 

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Full Transcript

Announcer: It’s time to think differently about healthcare, but how do we keep up? The days of yesterday’s medicine are long gone and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans, and many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together and hear some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.

Michael: Welcome to the “Paradigm Shift of Healthcare,” and thank you for listening. I’m Michael Roberts here today with my co-hosts, Scott Zeitzer and Jared Johnson. In today’s episode, we’re discussing what providers should be communicating about fees and how they can improve the billing experience. So, obviously, this is going to be a really easy thing to talk about, guys. You know, there’s never any question about how to talk about money when it comes to healthcare and there’s never any problem with it, right? Like it should be fine. 

So, obviously, billing is not a topic that providers like to bring up, but as a patient, we all have a huge concern about what it’s going to cost, what the insurance is going to do, what the doctor is trying to put into that. Like, there’s a lot of fear and anxiety that can go into this whole topic. So, why does it tend to be so difficult for providers to talk about pricing? I know this, obviously, can go in a lot of different directions, but let’s just start with the why behind it.

Scott: I think you kind of bring it straight up that when you’re practicing medicine, you’re just trying to practice medicine. You see a problem, you want to take care of the problem, and the dollars really don’t come into the equation, you know, when you’re in med school or when you’re in exam room trying to figure out what’s wrong with the patient. This is what happens, right? And then as you’re starting to practice medicine and you’re starting to do the same procedures over and over, you’re also seeing that some patients come in and they have one type of health insurance. 

And so, they pay, I’ll just make something up, $500 for that particular procedure, and then another patient comes and they have no insurance so, of course, they pay $50,000, and then there’s somebody who comes in with some other type of insurance and so on. And so, first of all, it’s extremely complicated. That’s part one. Part two, it kind of butts heads just with, “I just want to take care of my patients.” So, a lot of people that I’ve talked to over the years, they basically just kind of dump it on their staff. You know what I mean? “Oh, somebody will talk to you from the billing office about that.”

Jared: Right. Right. I think another part of that is just, in general, I mean, who enjoys talking about that when you know the conversation is just going to be terrible, no matter what? No one’s going to sit here and think, “Oh good, I’m glad I even paid $2 for this thing.” Like, nobody even wants to come do the thing. Nobody even really wants the procedure. They want to be pain-free or they want their quality of life to improve, but they don’t want to go through the procedure itself, let alone pay for it. So, sometimes it’s even just the basics of like, “Why would I even talk to you about that because I know you’re going to blame me and this isn’t all my fault.” You know, that’s how it’s looked at sometimes.

Scott: Sure. And, you know, healthcare in itself, like, there’s proactive healthcare where you’re just going in for checkups, etc., and you know that there’s a cost involved. You’re almost prepared for it, like, “I’ve got to go to the dentist and get my teeth cleaned twice a year.” Okay. I get it. And you kind of know the cost already. And it’s your choice. When you’re sick, first of all, you’re sick, so let’s start with that, either in pain, nauseous, etc., so you’re not exactly at your best, and then it wasn’t planned. So, it’s not like it’s really part of your budget. Some people love to go shopping for X because they want it, they have plan for it, whatever that is, you know, whether that’s a piece of clothing or a glass of wine, etc. But nobody thinks like, “Wow, this is great. I broke my leg and now I get to pay for it.” That’s just not the way it is. So, that’s part of the equation as well.

Michael: Yeah. I always think of it in terms of, you know, having to go get my van fixed for whatever thing popped up, and you’re thinking, “Is this a $100 problem?” “Is this a $5,000 problem?” And, you know, in my head I’m always budgeting for at least this much. I figure anytime I take it to a shop, that’s at least $200, you know? So, there’s almost like that kind of healthcare equation, but there’s just so many more people in the mix to figure out that final number. 

I was actually talking to a sales rep yesterday on behalf of a client, we were looking for a particular solution with a software they had, and it was hilarious to me how often this person would talk about all the features of the product but never quite get down to that cost. “I’ll send that to you afterwards.” And, like, this is this person’s job is to talk about costs all the time, right? Like, that’s a regular part of that negotiation. And so, even for people that this is the thing they do all the time, price is definitely one of those things that they try to stay away from.

Scott: Yeah. So, there is that taboo of pricing itself. There’s when is it appropriate to talk about cost? You know, I talked to a lot of providers where they just kind of start working on the workflow when the patient sees them, what they’re going to talk about in the exam room, and who’s going to talk about cost, about billing. And usually, they’ll leave the billing process to their staff. And to me, that makes sense. It’s like right now, as a provider, I would just want to talk about, this is your issue. And there’s a variety of things we can do to take care of you from, say, non-surgical…I’ll keep it staying away from surgery, but say from non-invasive to more invasive or less aggressive to more aggressive. 

And then they’re going to basically move you along to the billing person to talk about that. And there’s nothing wrong with that workflow, but I think it’s critical that the staff is extremely well-trained not just on costs. The healthcare companies have done a great job of complicating this process and making everybody feel a bit confused. I think that actually puts them in a better spot. And if any healthcare company wants to come and join us on a podcast to walk through their complex processes, you’re welcome to come join us. 

But, you know, literally, I remember talking to Terry Leidner, the Practice Administrator for Ridgewood Orthopedic Group in New Jersey, and she discussed ways that her staff will communicate with the patient. I’m kind of paraphrasing, excuse me, and she said, “It’s kind of funny because we found one of the things that frustrates our patients more than anything, it’s such a silly thing, but when we go to make an appointment for them, the first thing we ask them is, ‘What’s your insurance?'” And they’re angry. “What do you mean? You only care about my insurance?” It’s the exact opposite of that. It’s, “No, we’re trying to figure out how to better take care of you. 

What kind of insurance do you have? What’s the best way to manage the costs for you?” These things are important, and I do think explaining why you’re asking is important. There are other practices when someone will call up, they’ll start asking a lot of questions about what kind of pain they’re having, and some patients will say, “Why are you asking me about all this pain?” And if they’re good at what they’re doing when they answer the phone, they’ll still explain why they’re asking these questions. “Well, we want to make sure that you see the appropriate doctor.” You know, those things are important. Don’t you think, guys?

Michael: For sure. I have family members that are, I think, the best way to say is like inherently distrustful of the healthcare system. And there’s always like kind of a question about how qualified is this person to really make these decisions versus me making my own decisions. But the other side of it is, you know, hey, healthcare is just out to get your money. And so, if you hear this question and for any patients that are coming into this, they’re already scared about what this is going to cost. They’re already, you know, nervous about all this kind of stuff. 

You know, Scott, you and I talk a lot about how you view pricing and how you’ve used certain investments, you know, is this a, “I’m excited about this purchase,” or is this, “Oh crap, I’ve got to take my van to get fixed” kind of purchase. So, when people go straight to the money, it reinforces all that distrust. If that’s not set up, well, if that’s not explained as to how you’re going to be able to kind of like provide these different options, how you’re going to be able to make recommendations. In our country, it’s based on what insurance you have, and that sucks to some degree, and it’s good to some degree, but like that’s where we’re at. So, despite how much we might want to see things change, it’s where we’re at. So, how do we deal with that in a way that’s going to not throw up all those red flags?

Scott: Yeah. I think really what it comes down to for me is if I had to give advice to any practice, it’s explain what you’re doing all the time. You do that as a matter of fact when it comes to the health procedures. “I’m going to give you this shot, and this shot is going to do this. It’s going to hurt a little bit at first, but it’s going to go away,” you know, all that stuff. You just talk about regular, very minor kinds of procedures, like, anytime you do that, there’s a very well-articulated, at least I hope, and, in general, there is, “Hey, here’s what’s going to happen. Let me explain it to you. This is why I’m doing it.” That type of thing. 

And I think a similar philosophy, a similar modality needs to take place when you’re explaining costs. You know, Terry Leidner from up at Ridgewood Ortho, she really trained her staff very, very well about the process and why this is good, why they’ve got smart, intelligent people to help you through it. You know, they acknowledge that it’s a complex issue. They acknowledge that there’s a lot of hurdles to get over, “But don’t worry, you know, I’ve been here before, I’m going to walk you through this process because you didn’t ask to fall down and hurt yourself. You didn’t ask to have so much knee pain that you need a knee replacement, but I’m going to try to help you figure this out.” And I do think that that is a critical component to a successful conversation about that.

Jared: Yeah. So, if maybe the common thread here is even just asking yourself, “How can I communicate to show that I care about this patient?” I can’t just take it for granted that they know that. Their only encounter with me is, you know, what’s communicated verbally and non-verbally to them when I’m in-person with them. So, if I even just train myself to think, “How do I communicate to show that I care for them?” That’s going to lead most staff, I think most reasonable folks, most of those who are in healthcare, regardless of what position we hold from the clinicians, to the office staff, to everybody involved, if we even just ask that, if you’re in healthcare, most of the time, you’re going to lead yourself to say, “Okay, maybe I can do that one thing differently, maybe I can say that one thing.” 

I mean, the example of Scott of explaining what you’re doing throughout the process. I couldn’t help but think, like, I just went in for my annual physical about a week ago, and I was trying to picture myself. I was going to laugh at myself if my doctor, if he wasn’t explaining what he was doing, you know, even just during a basic physical, you might get upset. You know, and I got my flu shot too, right? And if they just like rolled up my sleeve and like stuck me without even saying anything, I might have been like, “What the crap? Like, what’s happening right now?” 

So, I was trying to imagine like what any office visit would be like with no communication. And so, I think like that’s kind of a good baseline here to think about. You know, so the other part of it to me is not having a defensive mentality. You know, regardless of how much is going on and how backed up things are, how stressful it is as a staff member or as the clinician, just thinking about, like, don’t just say, “Well, hey, these people are coming to me because they have to, you know, I’m just going to treat them like another number,” you know, treat this very transactionally. Just even a basic amount of empathy of putting myself in their shoes of like, “They’re probably scared, they don’t want to be here.” Even just thinking about it with that basic amount is going to change the way we communicate.

Scott: And it’s a time to really impress from a customer service perspective, from a patient service perspective. You know, we do a lot of reputation marketing development with our practices. We really firmly believe that reputation marketing is an important component of online marketing. And it’s very often not just how effective the doctor was, it was the entire office as a team. I can’t tell you how many times we’ve spoken to practices where, you know, we’ve had to kind of let them know like, “Hey, if you keep getting some bad comments about the billing person, it may be that you need to talk to the billing person.” Right? 

When you think of care, lots of doctors when they first start, it’s only about their component. “Well, I took great care of the patient, I don’t know why they’re unhappy.” It’s like, “Well, because after they left you and you took good care of them, the costs weren’t explained well by the billing department. They didn’t feel like they had their hands held correctly,” that type of thing. That could happen before the procedure, that could happen after the procedure. 

We’re very focused on billing with this, but it’s all part of that big component of like, just take care of your customer, take care of your patient. Because in the exam room, it’s a patient. When they’re not in the exam room, it’s a customer paying for something. It’s that simple. And they’re paying for something, just like you said, like the van needing repair, they are paying for something they didn’t want to pay for, but here we are. And if you got empathetic, knowledgeable staff, they’re going to feel really well taken care of, and that’s an opportunity to actually, you know, delight the customer. Right, Jared?

Jared: Yeah. And even just thinking about that, I’m glad you even brought that up, just the thought of delighting customers. I think that’s a big piece of this. So, I think there are some easy pitfalls that can be avoided with just some simple thoughts of some of the things you guys were just talking about. I’m curious what you think about that, Michael? Like, how can we help providers even just avoid some basic pitfalls?

Michael: Yeah. You know, we’re talking through some of these ways of communicating, and I think it kind of comes down to, what are the pieces that they’re going to be communicating? Like we’re saying, “Hey, talk to your patient, let them know what’s coming.” But, you know, Scott, as we were preparing for this episode, one of the things that you brought up was just sometimes the silly things that get overlooked about, make sure the anesthesiologist is actually going to be on your insurance plan. My wife delivered a baby this summer.

Scott: Yeah. You just stood by the side, but yeah.

Michael: I encouraged her, but we had somebody that came in and did a test, and I don’t even remember what it was, guys. Like, that’s how much like it resonated with me through the process. But then there’s like a $300 bill that shows up later on and this hospital is this particular group, and they just don’t work with insurance. And it’s like, really? Just really? That’s just silly, you know? It’s just, like, let’s talk through this kind of stuff. Letting people know. 

And if you are surprising people with these kinds of things and it is frustrating people, maybe you’re going to have to do something about that. Maybe you’re going to have to rethink that plan or you’re going to have to let people know upfront because I probably would have been fine with it even if they let me know, usually, these tests cost X. Because they don’t work with insurance, they could get that number. We’re very focused on that interplay between insurance and how each patient has to respond to that. But if you are working with those groups where insurance isn’t a thing, you can actually get some real costs, and you can actually communicate some of that kind of stuff. So, at least look for that. At least look for those opportunities.

Scott: You know, Michael, you’ve worked for me for a long time, for better and for worse, and one of the things that I constantly repeat is protect the client, protect the company, no surprises. And you can put that in any order you want, because they’re all equal. You’ve heard me say that a million times I’m sure. It’s the same thing. Like, you know, you’re talking about that procedure. And if they had said like, “Look, we’re going to do this test, and it’s designed to give us these answers. And unfortunately, it’s not really covered by your insurance, but I think it’s important. It’s going to end up costing $300.” You’d have been like, “All right. You know, what am I going to do? I don’t know how I’m gonna afford it.” 

Like, there’s some people lucky enough to say, “Hey, that’s okay, I can afford that.” There’s some people who might say like, “How important is it? I can’t afford $300.” I get it. But that would have been a much better conversation than for you to get this, you know, bill and be surprised by it, right, because that’s that no surprises conversation. Believe me, you’re not the first person to get that test and say, “Huh, what did I get billed for this?” And I can promise everybody, I got the best insurance I could get all my employees here in Louisiana, and it’s very good insurance, but it doesn’t cover everything because that’s the nature of most of health insurance out there. But if you had known ahead of time, Michael, you probably wouldn’t have been as irritated when you saw it. Correct?

Michael: Yeah. And if a group just flat out doesn’t work with insurance, it doesn’t matter what plan you have, and you’re going to get surprised along the way. But yeah, somebody saying just, “Hey, here’s what to expect with this process.” With our particular circumstance, we deal with a lot of scenarios, and just very much speaking to the patient side, I’m sure that we’re not alone in this, where we get that bill and perhaps this group didn’t quite submit the information correctly. So, insurance is coming back, “We can’t pay all that,” and then you kind of have to get into that fray. You know, you have to get into that conversation. 

And so, to have yet another one of those bills come through when it so easily could have… We’re starting to lump that in our heads of, “Crap, now we’ve got another one that we have to chase down, and here’s all the things that we have to do.” And that wasn’t even the case. Like, some proactive communication changes that whole dynamic, and now we’re not frustrated, we just at least know what’s going on. And, you know, I get it that so many people come at healthcare with a different mindset, but I think so much of what we’re saying here is like what you got to stop. Like, these surprises, these frustrations that we all go through, like some of these can really be avoided. Let’s try to avoid them where we can.

Scott: Yeah. I couldn’t agree more. It’s that surprise issue, right? Don’t surprise people. It’s such an important thing. And if there’s anything that I’ve learned over the years, it’s essentially, try not to surprise people, whether the information is good or bad. Give them the information they need. We can all make better decisions accordingly.

Jared: Yeah, exactly. And I think that kinda leads me to almost the golden question for the providers or, well, the staff as well. Whoever gets asked the question, “How much is this going to cost,” that part of this whole thing, when they can’t actually provide a true answer some of the time, at least right off the bat, you know, when they’re being asked, what do they say? Like what’s the best example that you’ve seen either as a patient or in counseling with providers that you’ve talked to, what is a good thing for them to say? Because I know that’s one of the big frustration points, is that they, “Man, don’t ask me.” You know, like. “It’s not all up to me. It’s not on my control.”

Scott: No, that’s a great point. It really is, Jared. You know, I can’t tell you how many orthopods I’ve talked to over the years. They’re as frustrated as patients are about some of the ways that health insurance companies basically manage information and what they do. And frankly, sometimes the best answer is, “I don’t know. You know, I don’t know what this cost is going to be, but what if we got on the call together with the health insurance company to get a better idea?” I know that Terry Leidner up at Ridgewood Orthopedics will work very hard with her patients to get the information that they need. 

And if they can’t get the information, they’ll let them know and why. I actually recently fell down and broke my wrist, and I had to have surgery. I’m fine, everybody. It’s all good. But that being said, I spoke to a good practice and the orthopedic surgeon said, “Hey, here are your options.” And I do think I ended up choosing surgery with the surgeon’s advice, and the next thing I was talking to the billing people, and they said, “Hey, here’s what we know. Here’s what we know the costs are going to be here, here’s my costs. In general, when you have this type of insurance…” And they had it down pretty much to a science on it, but there were some unknowns. 

And they literally said, “When you go to the hospital, we don’t control who the anesthesiologist is in your surgery. I think 95% of them are covered by your insurance, but if you request them, we can’t.” Can you imagine this? “We can’t, as the orthopedic surgeon request any specific surgeon, but you, as the patient paying for the surgery, can request that someone needs to be under insurance.” But they gave me the power, they empowered me with information. So, when I signed up the next morning, I said, “Hey, this is my insurance, and I only want somebody who’s covered.” And they were like, “Absolutely.” But can you imagine that the orthopedic insurance had nothing to do with that? But they told me what I needed to know. They told me what they knew and what they didn’t know.

Jared: That’s so funny. Wow, I wish that was an isolated incident, but you know, there you go.

Scott: No, no, no, it’s not. You’re absolutely right. It’s not.

Jared: Well, you know, I’ll tell you what, that kind of leads me to think about this in a slightly different term. When we just think about it from a customer, like a customer experience term, billing really is an opportunity to delight the customer. So, those are kind of terms we hear about points of delight. How do we delight a customer? When you think about the provider really might not have control like we were just saying, and they know it, so that’s what can lead to some of that frustration. But they really can still do a good job communicating and making it understandable. 

And Scott, that’s what I keep hearing you saying is that it’s not a huge switch that they have to flip. Like, it’s just thinking about it from a different perspective. It’s just realizing, “Hey, like, if we do this part right, then that’s the icing on the cake?” Like, we’re not only avoiding like a bad review. And so this kind of ties into the reputation management piece that you and Michael were mentioning just a few moments ago, and I’d love to hear your thoughts on that in terms of good starting points for improving communication when they realize, is it just helping the provider realize that that actually ties into their reputation and that can have an effect on things? Where’s a good starting point for them to think about it?

Scott: Keep communicating. What is everything that they need to know? Even communicate, “Here’s what we control, here’s what we don’t control. Here are the people that I talk to, here are the people you can talk to.” When I had the surgery, it was pretty quick too. I didn’t have a lot of time. It was a trauma surgery. Like I said, it was a fracture repair. But because they were so knowledgeable about what they did, they kind of triaged the cost perspective for me. And I go back to protect the client, protect the company, no surprises. Put it in whatever order you want. But if you’d follow those general rules, everybody will have a way to do that that works best for them, but follow that sage advice. And I think that’s the way to get started.

Michael: It’s very much a difference in personality kind of thing. So, there’s keep communicating, but I think keep listening as well. Like, you have patients that have gone through this process with you. And let’s not even, like, just talk about it from, “How do I look in Google,” or “How do I look in bar,” or what have you. You know that there’s a group of patients that you already have that have gone through the process and they’re happy with you, you’ve got those happy patients, but maybe they still have feedback on, “Man, I wish this could have been different.” “I wish I wasn’t surprised by this bill.” “I wish…” That kind of information. And if you can go back and get that kind of information or train your office staff to listen for it, because I promise you people are saying it in the office, you know, like, plenty of people are voicing their thoughts for sure. 

And so, if that kind of feedback can get back to the team, if that can actually come back, so it’s not just the office staff having to listen to people complain, right? Beause that’s what it can feel like is, “We’re just hearing all these complaints and it’s not ever going anywhere,” but you can turn that into, “Please bring that feedback to us so that we can actually make changes around this.” But those are the things that you can start looking for and start saying like, “Why didn’t they know this? How do we actually change this?” There’s a ton more that we could delve into with that, guys, and I want to be conscious of everyone’s time and wrap for today. But I think that there’s a lot of opportunity. And I think what’s exciting about this is that it’s not necessarily dramatically difficult things to do, right?

Like, we’re not talking about like, “Tear down your entire building and build a new one,” and all of that kind of stuff. It’s looking at the processes that you have. It’s having conversations with those sort of frontline personnel to say like, “Hey, bring this information back,” and training some of your personnel to say, “This is how we’re going to communicate. This is how we’re going to bring that loop. We’re getting this information out there.” Guys, anything else we should add as we’re wrapping up here?

Scott: No, I think you kind of hit it on the head, you know? It’s very funny you mentioned like I speak, so protect the company, protect the client, no surprises. You listen much better than me and I always remind myself, “Listen to Michael. He’s a smart guy.” Listen to your patients and then protect the company, protect the client, and no surprises.

Jared: Great to kind of end on that note of like this isn’t rocket science. Some incremental improvements can really improve this experience for everybody.

Michael: Absolutely. All right, guys. Thanks so much, and thank you for listening today.

Announcer: Thanks again for tuning into the “Paradigm Shift of Healthcare.” This program is brought to you by Health Connective, custom marketing solutions for medtech and pharma. Subscribe on Apple Podcasts, Google Play, or anywhere you listen to podcasts.