We sat down with Dr. Tal Taviv from Eye Center of New York & Austin Cheng from Gramercy Surgery Center to explore the impact of "the last impression" - how and when patients pay - on the overall patient experience. The following is a transcription of their discussion.

Sean Hanlon: Well, why don't we get started since it is 5 o'clock? Want to be respectful of everybody's time?

Thanks everyone for joining. This is titled The Last Impression: Why the Way Patients Pay Matters More Than You Think.

We're going to be discussing Tal and Austin's experiences addressing an often overlooked but critical part of the patient experience which is the payment process, or paying for surgery, especially when multiple providers or entities are involved. So the surgical practice, the surgery center, perhaps a co-managing optometrist, perhaps anesthesiologist for an all-cash procedure.

Historically, that payment experience is either potentially noncompliant or really undermines the overall high quality, patient experience that every practice and facility aims to create for their patients.

But first let's do some introductions, and I'll also just also say, if anyone has a question, you can throw it in the Q&A feature at the bottom of your zoom window there, and we'll do our best to get to them.

I’m Sean Hanlon, the co-founder and CEO of CoFi. For those who don't know what CoFi is, CoFi is a software platform that enables patients to pay multiple providers or entities separately and directly and conveniently.

The patient can pay the surgeon and surgery center, or the surgeon and a co-managing optometrist, or all 3, and again maybe throw anesthesia in there as well.

We’re solving for compliance, right? Enabling the patient to pay each party directly for their respective fees, so that one party isn't collecting globally and remitting payments to the others, and we're solving for the patient experience. And we'll talk a lot more about that today.

Last bullet point on CoFi. We're 5 years old. We've been commercial for just about 4 years now. We’ve hit 13,000 surgeons and optometrists on the platform and are nearing 100 surgery centers all in the in the vision space.

So that's an introduction about me and the company. Now let's just go around the room here. Dr. Raviv, introduce yourself and a little bit about your practice.

Dr. Tal Raviv: Hi, everyone! I'm Tal Raviv. I'm the founder medical director of the Eye Center of New York. We're a refractive, mostly cataracts and Lasik, practice in New York City.

Austin Cheng: Hi, everybody! I'm Austin Cheng. I'm the CEO of Gramercy Surgery Center. We're multi-specialty surgery center in New York City. We have 2 facilities. Ophthalmology is a large part of our of our case volume. I'm not a surgeon by background. I'm actually an attorney by background.

But I find myself running Gramercy Surgery Center. My mother is actually the founder of the facility. So I'm a second-generation owner, operator. I inherited the operations when my mother unfortunately passed a little early, due to terminal cancer. So that's why I sort of have found myself a trained, formerly practicing attorney, now running a surgery center. And it's a pleasure to be here and speak with everybody today.

Sean Hanlon: Great, great! Thank you both.

I'm going to sort of moderate this, but questions can come bidirectionally. We can make this a conversation. Tal, let’s start with you. I’ve been in your practice and I know that you'r ein Manhattan, and you're focused on the premium experience, premium procedures and so forth. Maybe just talk a little bit about that - the effort you've put in around the patient experience and some of the tools you use.

Dr. Tal Raviv: Sure. Many years ago I was a comprehensive ophthalmologist, and over the years I've morphed more into a cataract surgeon than a premium cataract surgeon, partly because of the market I'm in and where things are going. What the patients desire, what they want. And so when I built my practice, which is now maybe 4 or 5 years old,

we wanted to deliver two things: extreme competence and extreme kindness.

That goes into everything from how we design the place to how we train staff, the devices we have, and every little interaction we have. You want the patient to think “These guys know what's going on.”

The kindness and the competence are the pillars of making an outstanding patient experience.

Sean Hanlon: I like that, kindness and competence. I don't think I've heard that before.

So from the minute the patient hits your website, or calls your staff, or sets foot in the office and engages with the staff and with the doctors you're working to deliver the optimal patient experience and the theory behind this whole discussion here, and what we hear from our customers all the time, is that that patient experience can fall apart or be tarnished by a kind of klutzy payment journey. Can you talk about how that process used to look before CoFi, and some of the pitfalls, and what you were looking to solve for?

Dr. Tal Raviv: Sure. You know, when I opened up this newest practice, I was starting to do a little bit of co-management which is not as big in New York City, although it does exist, and I knew already that the patients were going to have to pay the optometrist or the post-OP medical doctor directly.

I didn't have a good way of doing that. So, we tried different ways. Our coordinator would explain, “This is the price here, and when you see Dr. Y for your post-OP, you’ll pay them.” Then of course, they got to Dr. Y a few weeks later Dr. Y would say, “You owe a few $100,” and they were just very confused. Boy, that was not pleasant.

Then we tried to be smarter. I didn't want to send a check to the optometrist. I already saw all the lawsuits, and the compliance issues of that. So we tried having the patient in the office and calling in the credit card to their surgical manager while they're there. It was, again, super awkward but it was compliant. The patient saw that there's 2 payments, and I'll just pay both now. But that was super awkward. And that's where CoFi solves.

Sean Hanlon: And then you ultimately decided you wanted to bring Austin into the fold, and so talk a little bit about that. The co-management is one piece, but most of your patients aren’t co-managed, right? So what’s the typical patient payment journey as the patient pays your office for the right eye and gramercy for the lens, and then double that again for the other eye. Is that how it happens?

Dr. Tal Raviv: Before CoFi, there was that option for the surgeon to pay as well. I could take the payment, and we did that for simplicity. But of course, I'd have situations where the patient wanted a receipt, or they wanted to bill something to insurance. It was not clean, it was not transparent, and that just wasn't what I wanted.

We want transparency. So that's why we brought Gramercy in and said, You know what? Let's put every part of the equation here, and of course that's what made it magical.

Sean Hanlon: Austin, turning to you. I've been in your facility, at least one of them, and I know that your orientation is. You want things to be as simple as possible for the patients when they show up and for the staff. I've met your staff, too, and I know that you put systems and rigor in place to try to reduce the burden on them. If you would just share your experience of trying to create a positive patient experience in your facilities and also how you deal with the payments with your ophthalmology partners.

Austin Cheng: Yeah, absolutely. So, I think a good place to start is back to our founding, actually, again, founded by my mother. She was not a surgeon. The typical surgery center has a base of surgeons that open up a surgery center together. But that was not the case for Gramercy Surgery Center.

It was sort of was baked into our founding, our dna, that we have to make things a little bit better to win over the business of the surgeons. If this is not the surgery center they founded, why would they want to use your surgery center? Why should they trust their patients to us, right?

So, we're always very sensitive to providing a very positive surgical experience at our facilities, and I like to bring up our origins because it's kind of born out of necessity. We’re always very thoughtful of the surgeon experience and also the patient experience. Those are both our customers.

CoFi, for us, solved a few problems. You mentioned the regulatory and compliance aspect of it, which I think is very helpful. There's also the experience aspect. It keeps things very nice and neat for our surgeons and our patients, but it also keeps things organized internally for our team.

And just to kind of take a step back, we have quite a few ophthalmic surgeons using our facility. I probably should have run the numbers before this webinar, but we have probably 30 ophthalmologists using our 2 facilities.

When you have 30 ophthalmologists, sometimes you have 30 different workflows, right? And that's not ideal. We try to push towards the more simple workflow. And I think we found a very simple and organized workflow with Dr. Raviv.

We want to create a simple and organized experience for the patient. We want the patient to see in one place what they owe for the surgeon, for the facility fee, and potentially for anesthesia. CoFi puts that all together.

Prior to CoFi, like Dr. Raviv mentioned, there were arrangements where perhaps the surgeon tries to make it a good experience for the patient by collecting everything so the patient won't have to pay anything at the facility. There are other workflows that we've implemented at Gramercy, where the surgeon will collect their portion. We will collect our portion from the patient, and that gets a little confusing.

So all in all, the workflow that we've implemented with CoFi has helped tremendously with that organization.

Sean Hanlon: That's great. Let's talk about that second to last point you made there about the confusion, where the patient has 2 different payment events - the surgeon and your office and your facility. We know that often can be 4 payment events, because a lot of times they're paying one eye at a time.

So when you say confusion, how does that manifest? Dr. Tal, you can weigh in on this as well.

Austin Cheng: There's a level of education that has to go into speaking with our patients. And I think there's just a baseline understanding in our country that healthcare is very confusing. So as a provider, you want to make the experience as seamless as possible. If you're a patient, you want to understand what you're paying upfront, what the different components are broken out, and you don't want to be surprised with another bill later on.

But I think when you talk about it out loud, it makes sense that a surgeon has their own fee for their service, a facility has their own fee, and an anesthesiologist would have their own fee. But sometimes you have to explain that multiple times to patients. Not everybody is in the healthcare field and trained to understand all that. So there's frustration that comes when they are presented with what they believe to be an additional bill or a bill that they did not fully understand.

Sean Hanlon: The ophthalmology practice team may do a great job of explaining to them what they owe and to whom right? But time passes, and later at the facility, or even downstream from that at the optometrist's office, that can be weeks after they make the first payment. We hear this all the time - They can get confused, and sometimes the facility stuff or the optometric staff get frustrated with the surgeon staff, thinking they're not doing a good job of explaining it right. And you get some friction there when really they did tell them everything. They have the paperwork they signed. But they've forgotten.

Dr. Tal Raviv: Think of a hospitality space. If any of us have been fortunate to be in a nice hotel, sometimes the nice hotels will pull you aside and they'll do the check in at a little counter and give you a nice beverage because they're doing everything to reduce the friction. They don't want you waiting in line. Payment is very important, and they need to get your credit card but they want to do it in the most painless way.

So for us, we’ve agreed upon a price and we want to make this transaction. CoFi creates that very seamless invoice that has all three parts to it. We can even email it to the patient as an invoice. It’s just very easy to understand. It's just an elevated experience

Sean Hanlon: That's great. The other component that I think is worth talking about is how the patient can pay, specifically around the use of patient financing.

With these high-dollar premium procedures, often patients are looking to finance them. And what we found is that when patients want to finance, they want to finance the entire procedure. They don’t want to finance the surgeon’s portion and then have to come up with separate funds to pay the facility for the lens. And sometimes they won’t go through with the procedure if they can’t finance the whole thing.

Dr. Tal, I know that financing is not a huge percentage of what you're doing in your practice, but I know you use it. Talk about that for a second.

Dr. Tal Raviv: Yes, when we financed it was for us and we’d try to explain to the patient “Well, you still have to come up with a thousand dollars for the lens on the day or surgery.” It was uncomfortable.

It definitely was a huge barrier to having the procedure done. They'd have to finance only part of it.

I’d always ask CareCredit, and they would say the money goes to you. There’s not other way around that. Then lo and behold, CoFi launched that product and its kind of like a magic button because it lets us do it the way it should be. It's a very nuanced product that really thought of everything

Sean Hanlon: Good. The other aspect I think is happy patients come from happy staff members. Looking back on some of the challenges with the patient again, what kind of impact do you see from resolving those issues on your staff? Did you find an improvement for their administrative burden?

Dr. Tal Raviv: CoFi is sort of like a central nervous system. It’s a dashboard, and as you’ve described it to me once, it’s one source of truth. We have the payments to all the parties, to the facilities, and who has financed. It just makes it much more comfortable for our staff. And if our surgical coordinator is out, the next person who's coming in can just go right in there and see it. And of course, with the patient, the fewer phone calls we have of patients who may be disgruntled about a bill or don't understand, or had to cancel surgery, or from optometrists who are unhappy. CoFi solves for those things, especially with our staff.

Austin Cheng: We want a workflow that minimizes errors and is able to be repeated with accuracy and doesn't take much work.

So CoFi is good in in the sense that, just like Dr. Raviv said, there's a single ledger that shows all the payments coming in. The payments start to populate before surgery, and there is less a requirement to actually call the patient and do that education because the patient has already gone through that at Dr. Raviv’s office. They’ve understood, consented, and made the payment. So that portion of our workflow is reduced tremendously, and we can just look at the ledger and compare it to the patients we see that day.

It provides a lot of organization compared to a workflow where the surgeon has tried to create a single collection point at their office, but without a tool, and they then need to let the surgery center know.

So I think that sort of confusion is removed from it, and on the day of surgery it also reduces the front desk discussion. The front desk is the last line where they’re able to explain an invoice to the patient. That entire conversation is removed through CoFi’s workflow, because it has already occurred.

Sean Hanlon: What you described is exactly what everyone's trying to solve for. And you made the point earlier about the typical healthcare consumer used to being a little tortured. Certainly, they're used to paying multiple providers, right? No one's surprised by that. But why should it be so complicated? The analogy I like to give is, you can get a flight and a car rental in a hotel from 3 different companies all at once because all those costs are known, they're being presented to you. Someone's managing that price list, and it's being presented to you, and and you can make that payment.

Why can't we do that across healthcare? Starting with these vision surgeries.

So you guys just rattled off collectively about 9 or 10 things that were problematic from a patient standpoint, and then also corresponding number of issues around your staff and the work required to have those conversations and deal with confusion and collect payments. That’s really what we’re trying to shed light on here, and why we’re doing this talk tonight.

Do you guys have anything you want to add?

Dr. Tal Raviv: I just want to add that CoFi has been well thought out to reduce the friction and make these workflows seamless for our staff, especially for the patients in unusual situations where they have paid and then change their mind and cancel. We press a button, and it's able to reverse that payment and make a refund from both providers.

It's transparent. It's beautifully laid out on this ledger, and it's the way I wish the rest of healthcare was.

Austin Cheng: As I mentioned earlier, we have quite a few number of ophthalmologists at our facility. Our goal from here, now that we’ve identified this solid, reliable workflow that does not add much additional work, is to spread the workflow to other ophthalmologists and spread the good word that there's this product that is able to help us organize and provide a better experience for the patients.

So we're excited to share that with some of our ophthalmologists, and hopefully they agree to that so our workflow is all organized.

Sean Hanlon: That’s great. One of our attendees has asked, “Our practice participates in co-management. We have an OD that requested our facility to pay all the transactions. It seems like a compliance issue. I can opine on that briefly.

So the rules of the road, Elizabeth, is that each party should set their own rates for the work that they're performing. So the surgeon sets his or her rate for their professional fees, for any cash, or premium component of a procedure, and the optometrist should set his or her own rate for the post-OP work that they're performing in both cases.

The patient should pay each party directly. So one doctor shouldn’t collect for another doctor and remit payment to them, especially if there’s a referral relationship between the two which there certainly is between surgeons and optometrists.

I'm not an attorney but I certainly have learned a lot about this, and we've talked at a lot of meetings about this topic as well. But yeah, that's a no-no. And at minimum the optics on it are poor.

And this is another good point Elizabeth is bringing up, she just added, including transaction fees. So one of the things that's also important to mention here is in the event the surgeon collects a global fee and then remits a payment to, let's say, the surgery center for the lens or the optometrist, right? That surgeon is incurring credit card processing fees. When they write that check, if they’re not deducting those fees, they’re providing something of value to the surgery center or the optometrist, actual money and that can be viewed as an inducement for referrals.

This is relevant for surgeons and surgery centers, too. There's a lot of instances where the surgeons are collecting for the lens on behalf of the surgery center. And then when they settle up later, they’ve incurred those costs for the processing fees for the surgery center. That’s not something that should be happening.

Alright. Well, in summary, I appreciate everyone coming out. Thanks to Austin and Dr. Raviv for joining tonight. This was an interesting conversation. Appreciate everyone who joined, and thanks for your time tonight.