All Posts tagged CEO viewpoint

Healthcare bills are confusing

Keith Gnagey, CEO

Keith Gnagey, CEO

When it comes to making improvements in our billing process, our most valuable resources are our patients and their families. Concerns, complaints and suggestions from our patients have led to changes throughout our entire business cycle including changes in our processes, staff training, and software changes. We get patient complaints for less than one percent of all bills we send out, but we know that doesn’t help if you are the one with a billing issue.

If at any time you or someone you know has a question about their Teton Valley Health Care bill, please be sure to give us a call or send an email or letter requesting assistance. While it may feel therapeutic to turn to your neighbors or Facebook friends, we appreciate direct communication otherwise we won’t know about the problem and can’t fix or answer the concern.

Here’s an overview of how our billing cycle works, along with definitions of different billing terms.

When we send the first statement after a patient visit, it’s a detailed list of services. Every statement thereafter is a summary of the balance remaining, not a detailed list. We believe this provides patients with necessary data, but it doesn’t overwhelm patients by repeating the same details multiple times. If you ever need a detail for any of your visits, we’re happy to provide that for you along with any assistance in understanding the details.

We don’t send a statement for a service until the claim has been processed by the patient’s insurance. This helps to ensure that a patient is only billed for the amount they owe TVHC and that any insurance issues (eligibility, deductibles, and coverage terms) are dealt with before we ask you for payment. We do everything we can to provide a correct claim to your insurer immediately after the care is rendered. We want to see the insurer quickly and correctly process the claim as much as the patient does. If we’ve received incorrect billing information (this is why we always ask for your insurance information when you check in), if the insurance doesn’t process the claim correctly, if the insurance company needs additional information such as accident verification data, or if there are any other problems with the claim, it can take several months for the insurer to process and pay for the claim.

You’ll know when your insurance has processed your claim when you receive an Explanation of Benefits (EOB) that shows what you may still owe after your insurance has paid for any covered services. If you disagree with your EOB, you should contact your insurance provider for clarification. Most claims (bills) are sent to the insurance company and processed by the insurance company within 3 weeks of the date of service, so you should expect a TVHC bill 3-4 weeks after your visit.

Once the patient’s claim is processed by the insurer, or if the patient is uninsured, we send out the first statement with a list outlining the provided services. We then call each guarantor (the person listed as responsible for payment) within two weeks of that first statement to ensure that the statement was received, that it’s correct, and to see if there are any questions regarding the statement. This is not a “collections call”; it’s a courtesy call from our billing office offering to help you with any questions about your bill. If the statement is received and correct, we offer to accept payment immediately (we do accept most major credit cards).

We continue to reach out to the guarantor by phone and in writing (at least monthly) until the balance is paid or a payment plan is established. We work with patients who are unable to pay their bill by offering payment plans, assistance in applying for insurance, or through our financial assistance program. However, if a patient or guarantor doesn’t respond to our letters or calls, or fails to make necessary payment, we refer the person to a collection agency after 120 days. This is an action of last resort.

In addition to your hospital or clinic statement, you may also receive statements from other providers such as radiologists and pathologists. Multiple statements and potentially multiple explanations of benefits from insurance companies can complicate the process.

We want our patients and their families to be as satisfied as possible with our care and we’re available to help you navigate the statements, instructions and explanations that you may receive. We want to hear from you.


Contact us via email or phone.

Christy James, Financial Counselor, 208-354-6331

Keith Gnagey, CEO: 208-354-6355

Cadi Greenfield, Revenue Cycle Manager: 208-354-6323


Focusing on Patient Care

Keith Gnagey, CEO

Keith Gnagey, CEO

As a resident of Teton Valley and as the CEO of Teton Valley Health Care, I am concerned about how TVHC is perceived. If people in our community have a poor perception of our services, prices, or staff, they won’t come to us for their care. I understand that how we treat our patients determines how you (and the people you talk to) feel about the hospital. Like any service organization, if we don’t meet or exceed your expectations, you won’t be happy.[br][/br]
Teton Valley Hospital is a great little community hospital with a lot to offer. Our infection rates are always low (last year it was 0% …) and our clinical quality is high. Our patient satisfaction scores are consistently above 94% for both hospital and clinic services. We have very good equipment and staff. We have a 7×24 emergency room, clinic hours 7 days a week, and we employ over 150 people. In terms of the delivery of medical care and County economic impact, our 75 years of existence have been a crucial asset for Teton Valley. [br][/br]
I know that in the past we had billing issues and operational missteps. I know a number of people in the community were faced with those issues and because of their poor experience with TVHC they’ve chosen not to use our services. The good news is that we have made significant improvements in billing and other processes. The bad news is that many people don’t know that we’ve made clear, consistent improvements, and we believe we’re able to offer a better all-around patient experience. [br][/br]
It takes time to earn and maintain trust, especially after trust has been broken. If you avoid using our hospital or clinics because of a past experience or what you’ve heard second-hand, please give us the opportunity to change your mind. We’re still not perfect, but we are a lot better. [br][/br]
This year, TVHC is going to focus even more on you, the patient, and your family. You’ll see the following changes:

  • We are training all staff to improve the customer experience. Just like 5-star hotels train their staff to make the customer experience better, we are training all of our staff to better serve you and understand your personal needs. If one of our staff does not meet your needs, please let me know.
  • We’re improving the look and feel of patient rooms and exam areas such as our blood draw room, clinic admissions, and medical imaging suites. We are replacing our X-ray/fluoroscope with up-to-date equipment and we’re redesigning the X-ray room. The lab room is now complete. Look for the new X-ray equipment and redesigned room in May, and the Driggs clinic changes in June.
  • We will be adjusting our prices for imaging (e.g., X-ray, cat scans) services to make them more competitive. Look for announcements this summer.
  • We are investigating new evening clinic hours to accommodate everyone who works during the day.

Teton Valley Health Care is celebrating its 75th anniversary of service this year. We were built by a determined, conscientious community through much self-sacrifice and commitment, and we completed our first year of patient care in 1939. We’ve been through a lot of change together.[br][/br]
Like you, we have to anticipate changing times and that often includes making changes in course and improving how we perform. If you haven’t been here for a while, please consider visiting with us and let me know what you think of us now.


The price of safety

The price of medical care in the US is a topic of conversation that leads to sharing of personal stories that can be frustrating at best and shocking at the worst. At TVHC, we agree that overall, healthcare should be more accessible for everyone. The devil is in the details and to get to the details, it’s crucial to understand what drives costs for small rural hospitals in particular. Here are some answers to many of the questions I hear about our hospital costs.

How much does it cost to meet your daily, monthly and yearly expenses? Do you know how much of your expenses are fixed and how much you can vary? A fixed expense is one you pay regardless of usage, like your mortgage or a car payment. You pay the same amount each month whether you are in the house or on vacation, and regardless of the number of miles you drive. A variable expense is where you pay based on usage and have some control over how much the bill will be, like your cell phone bill or cable bill. Why am I talking about this? Because we want you to understand that Teton Valley Health Care, like other companies, has fixed and variable costs, and that we have to ensure that our revenue covers both types of costs.

Like many firms, our biggest expense is the cost of salaries and benefits for our employees – this consumes over 60 percent of our monthly expenses. Some of our staffing costs occur regardless of the number of patients we treat. We staff 7×24 nursing coverage. We average 1.3 inpatients at any time, yet a single nurse could manage 6 or more patients simultaneously. We staff providers at all times in the ER, yet we average only 4.43 ER visits per day. I can go on with examples in the lab, the pharmacy, x-ray and imaging, etc. Why do we do this? Isn’t this the waste and inefficiency Washington keeps referring to? We staff to provide appropriate levels of local care 365 days a year, so we can be there when you need us.

I would love to “fully utilize” our RNs and ER providers. But we can’t staff an RN for only 10 minutes an hour, and you wouldn’t want us to have to call in a provider every time someone visits the ER. Not only would it significantly degrade the health care we provide, it would also put us at odds with some of the regulations governing critical access hospitals (not all regulations are bad). I don’t want to imply that we cannot control our staffing costs, in fact, 43 percent of our staff is part time or pool, and we always keep staff on call for surges in usage. Our ER providers also offer clinic coverage on the weekends and cover our hospital inpatients. Our neurologist, pain management specialist, and general surgeon are only here part time. But there is a base level of staffing (i.e., fixed cost) that we must maintain. Our costs are higher than larger hospitals because this base level of staffing is not as fully utilized as at larger hospitals; our cost is spread over fewer patients.

We maintain a 13-bed hospital and average 1.3 patients at a given time. We have some of the best imaging equipment around and use it 1/100 of the time that larger hospitals do. We have to follow the same regulations, reporting requirements, and documentation requirements as other larger hospitals, but we have fewer patients. We need the same electronic medical record systems as larger hospitals, but we spread that cost across fewer patients. This is not a gripe, this a fact of life for most rural hospitals. It costs more for us to operate per patient served than larger hospitals.

So what do we do? Our community has clearly said that a local hospital is a requirement. We agree. Without a local hospital, people would suffer more debilitating injuries and more people would die from emergency medical conditions. We would lose jobs, productivity, property value, and potential new community members.

We are working to grow, to become more efficient, and to better serve the community. We know that healthcare is expensive and that every dollar counts. We are committed to reviewing and adjusting our prices, making prices more transparent to the community, and working with those in need to assist in payments. But no matter what we do, we are, at times, going to be more expensive than other alternatives for health care that you may find. I don’t want to mislead anyone. The price of having a local hospital is that it will be more expensive. Is it worth it? Absolutely!

You have every right to ask what steps we are taking to lower the cost of health care. Those steps include:

March 2013
  • Increasing the amount of services we offer and therefore the number of people who use the hospital and clinics – when we increase usage, we reduce the average cost per patient
  • Consolidating purchasing, constantly reviewing what we spend, and partnering with other facilities to help share or reduce expenses.
  • Making smart decisions on what services are necessary — offer those services with the greatest benefit to the community and the most attractive cost profile for our size of hospital
  • Partnering with other local hospitals to expand medical services that we don’t have the volume or capabilities to offer locally – expanded oncology care is one good example; we offer chemotherapy now and would like to offer further exam and treatment services.

In my next column, I’ll talk more about prices- how we set them, what we are doing to adjust them, steps we are taking to make pricing more transparent – and how to compare prices for healthcare. As always, I welcome comments and suggestions from the community. Please email me at