“It’s probably one of the only industries that what you bill is never what you get,” Tahoe Forest Health System CFO Crystal Betts tells me as we sit down to talk hospital finances. “You go to the store, you want to buy a gallon of milk and it’s $3.69, and you go up and pay $3.69. That doesn’t exist in healthcare.”

I was meeting Betts to discuss the district’s recent rollout of a program designed to walk anyone with a phone through the hospital’s billing practices and other issues that have been difficult for patients to interpret in the past. Betts has worked at the hospital for 12 years, and was instrumental in designing the program from the ground up — the first of its kind in the country, according to the district — to connect patients with customer service representatives trained to make sense of what she calls the “moving target” of healthcare finance. Here are some takeaways from the program, and healthcare billing in general, from a conversation with Betts and hospital district CEO Harry Weis.

Let’s start out with the greater, national issue of hospital billing.
WEIS: The national conversation with hospital billing, or even just healthcare billing in general, is a dilemma … the American Hospital Association has found four out of five Americans don’t understand how their health insurance policy works or how healthcare provider billing works because of the complexity, the large variations, and the changes annually that many health plans put in place.

CRYSTAL BETTS is the chief financial officer at Tahoe Forest Health System, where she recently spearheaded the effort to design the hospital’s new customer service program from the ground up and put it into place this year. Courtesy photo

BETTS: And there’s a lot of other, I’m going to call them plans, that have crept up over the years that consumers think are health insurance plans and they’re not … Even though it’s a lower premium on a monthly basis, the coverage is never what they thought it was, and they feel misled … So part of this program is to help educate the public about insurance plans.

So that was a large part of the impetus for the program, but what else inspired this service?
BETTS: A lot of the time [the patient] will get a bill and they think it’s our hospital that sent them the bill and it’s not, but they don’t know how to resolve whatever issue they might have related to that bill … so we decided, whether it’s our issue or not, let’s make the connection to that billing agency or to whatever it might be to help that person.

What was the timeline with this project and what did it take to put it in place?
BETTS: It was probably around June or July of last year that we challenged a couple of our departments and our team members to take the feedback they’ve heard from the interactions with our actual patients: What questions are they asking? Where are their frustration points? What information are they asking for? Taking that feedback that we would get on the phone or in person and go, “How can we create a program that addresses all these areas?” … We hired an additional seven people, we put them through weeks of training and, finally, we were able to do a soft launch in October … We were ready to get it out to the public in January.

Now that it’s a few months in, what has the response been? What successes and challenges has the program met?
BETTS: Right now we’re averaging a [customer satisfaction score] of eight out of nine overall. At the end of February we’ve answered about 8,000 phone calls … We only have about a 3 percent call-abandon rate. We have about a 30-second time to answer … So far the program [has] been very well received, with good feedback. We’ve definitely had some phone calls of lessons learned where we have to go back and advise staff or do a little more education in a particular area, whatever it might be. So, we’re continually trying to refine the program but I’m quite pleased with my team and how well they’ve been able to carry this out.

It was about the same time this program rolled out that a federal bill passed requiring hospitals to post their rates online. How has this played out in practice?
BETTS: I appreciate where the government was coming from when they wanted hospitals to post this publicly. The problem is, a hospital’s chargemaster has thousands and thousands of lines that are all connected to codes on how you bill. Unless you might be a biller, or some part of the financial aspect of the health system, or just have been doing it for a long time, you’re not going to know what to look up even on those publicly posted chargemasters.

WEIS: Each bill could include 50 to 100 or even a few thousand charges depending on the [procedure] … I’ve looked at the 360 hospitals that exist in California and what successful hospitals do is they look at averages — what are charges per discharge or charges on average per ER visit or per outpatient visit? That’s the only way you start to see something meaningful.

BETTS: And I would say, all they are is charges. A charge is meaningless, really, to the patient. So, unless the patient knows how the insurance plan has contracted with the facility, and then understands how their particular plan they bought then will pay for that, it’s still just a charge … This $15,000 charge could be $1,000 to you when it’s all said and done. But all they see is $15,000. It’s meaningless until you take them through the contract with the health plan and then you take it through the patient’s portion of what they are responsible for to get to the final number.

Is that a process that this new service can accomplish?
BETTS: Yes. The intent is, ‘Hey, I’m scheduled to have a scope on my right shoulder, what’s it going to cost me?’ … We’ll do all these calculations and say, ‘Okay based on a typical right shoulder scope, and your insurance plan, we expect your out-of-pocket to be X,Y,Z.’ The best we can do though is an estimate. If the surgeon gets in there and goes, ‘Oh my gosh, we’ve got a lot of scar tissue in there it’s going to take me a lot longer to do this,’ things can arise that make that estimate plus or minus … We try to get as accurate as we possibly can with the information we know at the time.

Tahoe Forest Hospital main entrance. Photo by Wade Snider/Moonshine Ink

I think there’s a general sentiment that costs are higher here at Tahoe Forest, is this true?
BETTS: So, we’re not. We do comparisons all the time and, again, this is a difference in public perception. You can go and publicly pull any hospital’s chargemaster in the state of California and you can flat out compare, code to code, Tahoe Forest to Barton to Sutter Auburn to Marshall, Placerville, whatever you want to do. Matter of fact, we do it all the time … You can go and compare [the top 25 most common outpatient procedures] at any facility and we know we aren’t nearly as expensive as other facilities in the state of California. And that’s important to understand, that California has different rules than Nevada does, and hospitals have different rules than outpatient centers. So, we get compared all the time to Reno Diagnostic. Reno Diagnostic does not have to be 24/7 in the services they provide, they don’t have to accept all payers, they don’t have the state of California regulations and rules that they have to deal with, they don’t have as much of the billing rules that a highly regulated hospital has to deal with, and so they have the capability of doing things differently.

WEIS: We operate in a cost of living index area that is significantly above the California statewide average and yet our costs are more than 50 percent below the statewide average. What a unique contrast. So, it’s an almost unparalleled value for healthcare, to receive healthcare in an expensive healthcare industry. That’s the bottom line.