Joel French, EVP of Patient Experience at R1 RCM, Inc.

The COVID-19 crisis has upended many of our traditional business procedures and processes. However, because digital transformations were well underway before the pandemic, the shift to remote work and contactless consumer self-service was swift. In healthcare, digital strategies that were expected to take 10 years to accomplish may now be compressed into three. That acceleration is especially evident with the “digital front door” – a strategy for engaging patients at every major touchpoint of the care journey using self-service technology they have already adopted for everyday use. 

The need to offer consumers more self-service capabilities, including finding a doctor, scheduling an appointment, and paying a bill is well understood. Yet, as Harvard Business Review reported, “Many health systems nominally offer these capabilities now through patient portals with often opaque user interfaces and erratic performance.” To be effective, the digital front door needs to be viewed more broadly than making individual transactions easier. The digital front door should be viewed as the storefront to a health system’s digital marketplace. Consider how people plan travel. Consumers use a marketplace, such as Expedia, to research a destination, consider travel mode and lodging options and assess associated costs – all before booking anything. Consumers want to be able to shop for healthcare services in a similar fashion and make a fully informed choice before booking an appointment. 

However, this level of transparency and consumer control remains a challenge. Patient financial responsibility is often hidden within the complex arrangements among healthcare providers, health plans and government agencies. Even for professional revenue cycle staff, it can be difficult to efficiently ascertain a patient’s estimated out-of-pocket cost, based on eligibility, network participation, benefits or co-insurance, let alone communicate that information clearly to the patient. While new Price Transparency regulations are well-intentioned, anyone familiar with chargemasters understands how difficult it would be for consumers to use them as decision-making tools. What’s more, from the health system’s perspective, booking resources before the patient is financially cleared can lead to cancellations and last-minute reschedules that leave costly resources idle and may result in payment denials.

The Digital Front Door as the Trigger for the Revenue Cycle 

Viewing the digital front door as the gateway to a health system’s digital marketplace, like Amazon or Expedia, allows the patient’s financial decisions to take place as part of the shopping experience. Shifting the start of the revenue cycle upfront enables the digital marketplace to intelligently match its supply of healthcare services with consumer and patient demand while assuring conditions for clinical appropriateness and financial clearance are met. The key is to optimize front-end processes as consumers enter through the digital front door via three key conduits: Consumer/patient self-referrals, provider referrals, and proactive care management to serve value-based care contracts. 

In each of the three scenarios below, the consumer should be presented with all the information they need to make an informed choice prior to booking their appointment, including in-network participation, member benefit eligibility, health plan authorization requirements and expected out-of-pocket costs, as well as their preferences for provider, location and time. 

1. Consumer/patient self-referral: When consumers decide they need healthcare services, such as a routine care visit, health-related class, or birth center tour, they expect to find what they need through an internet search. In parallel, the health system makes its services are known in the market through the same methods as consumer businesses – search engine optimization, digital advertising, and outreach via email and social media. The consumer’s process starts with a search, which leads to an evaluation of potential providers who can meet their needs. For example, a consumer looking for a routine screening mammogram searches online based on preferences for provider, location, insurance, and out-of-pocket cost. With a clear, intuitive process through the digital front door, the consumer assesses her options and books her appointment at an imaging center near her home that costs less than the nearby hospital.

2. Referring provider order or referral: In the second scenario, it is the provider who drives the process. As health systems seek to stem network leakage from their employed and affiliated providers, they need to facilitate the didactic process toward diagnosis and treatment. Through the digital front door, a physician can send an electronic order for an imaging study with the specific clinical requirements, reason, and legal signature directly to the health system. The completed order triggers automated financial clearance followed by a linked invitation to the patient to book the appointment online – also through the digital front door and based upon that patient’s preferences. This makes it easier for the patient to follow through, resulting in faster progress to the next steps in care. 

3. Value-based care management: In the third scenario, the care team uses knowledge of a specific patient’s condition or of a cohort of patients with a chronic condition to actively manage care, according to a care plan or value-based contract. Using evidence-based clinical pathways, patients and providers can be prompted to proactively schedule care activities intended to prevent avoidable care interventions or a worsening condition. For example, a diabetic care order set can drive online scheduling through the digital front door for a patient’s full year of care – quarterly A1C checks, annual foot, and eye exams, and nutrition counseling. At the same time, the patient can understand all out-of-pocket costs associated and consider payment arrangements as needed.

Leveling Up the Service Model in Healthcare

The traditional process of commencing financial clearance after an appointment is scheduled and health system resources have been committed leads to rescheduled appointments, care delays, unexpected patient costs, payment denials, and wasted resources. Instead, wherever possible, complete revenue cycle clearance, such as network and eligibility checks, prior authorization determination, and medical necessity confirmation, in parallel with the physician order or referral and prior to appointment scheduling. This provides the opportunity to not only improve the experience for consumers and patients but also to dramatically improve care outcomes and health system financial performance. 

Through the digital front door, health systems can offer consumers and patients – and providers who refer their patients for care – a structured, guided process for choosing the services that best meet their needs, clinically and financially. At the same time, the health system can align clinical appropriateness with payment to load balance their capacity with known demand. With the digital front door as the entry point to the digital healthcare marketplace, a substantially more convenient and effective service model is possible.