HOW TO HELP THE HIGH DEDUCTIBLE PATIENT

Strategies to help patients manage their healthcare bills

By Greg Snow, Vice President Provider Portfolio Strategy at Availity LLC

The public is being primed to take on more financial responsibility for their healthcare costs, with unprecedentedly high deductibles and co-insurance among the most notable drivers. It’s expected that even more employers will offer these high-deductible plans in 2016, compelling employees to pay for an even larger portion of their healthcare services. That is, if they schedule them at all. Many aren’t. In 2014, a widely cited Gallup poll reported that a full 34 percent of the privately insured had put off medical treatment because of cost concerns—a big jump from the previous year, when Gallup reported that 25 percent of the privately insured had delayed treatment.

 Although many predicted this is exactly what would happen if more costs were shifted to patients, an opposing view prevailed—that patients would just make more judicious use of their healthcare dollars by seeking care in less expensive facilities than the emergency room. In reality, they are delaying care until it becomes an emergency. At this point, care can only take place in the rushed and complex (and highly expensive) environment of the emergency department. So what can hospitals do to help people make better decisions about their care?  

As it happens, they can employ strategies that will also increase patient collections, which needs to be addressed in this new era of high deductibles and co-insurance. Just as important, these strategies will enable unique opportunities to lead patients through a new and daunting learning curve: the real cost of care and how to pay for it. To effectively carry out these new methods, providers will need specific tools and capabilities they may not already have. These include:

  • Quick and accurate estimates of the patient’s financial responsibility, based on a broad-spectrum evaluation that includes eligibility, benefits and authorization status
  • Forecasts of a patient’s capacity to pay, not based on intrusive credit checks
  • Multiple payment options and patient assistance plans
  • Proactive and consistent denial management policies

While not a complete list, it encompasses the most essential aids to help guide both the patient and the hospital through healthcare’s transition to value-based care. Below are some of the top scenarios where patients will need guidance—and cost clarity—in this era of heightened financial responsibility.

Scenario One: Patient is shopping for services but unclear on his/her coverage.  

For many would-be patients, calling to inquire about prices will be their first contact with a provider—and there’s quite a bit at stake if this initial interaction regularly doesn’t go well. Losing patients to other providers is one obvious risk. Acquiring a long-term reputation as a confusing price estimator and unhelpful communicator is another, thanks to CMS-led consumer rating scores and Yelp-like reviews online. Expect communication with providers about pricing to take on a more influential role in these reviews.  

 

Strategy: Have accurate price estimates in hand.

Note the operative word accurate. When patients know in advance exactly (or close to) what they are going to pay, the overall patient satisfaction will increase due to the elimination of any unpleasant billing surprises. Correct estimates also give patient access staff an indispensable tool addressing patient collections upfront, which hospitals will need to do to move the needle on revenue.  

Automated patient pricing tools are now affordably available on a software-as-a-servicemodel that generate all the needed information to present patients with an accurate estimate. These estimates are based on the patient’s most current levels of coverage and benefits used year-to-date, but advanced tools can even obtain authorization and medical necessity information. The latter are recommended to supply patients with estimates based on the most comprehensive information available. Obviously, an estimate that omits the fact that a particular procedure won’t be authorized is setting both the patient and the provider up for uncomfortable news down the road.  

For hospitals that don’t want to add more technology internally, outsourcing is another option.  

 

Scenario Two: Patient doesn’t know how he or she will pay.  

This is a worry that was expected to evaporate, or at least greatly diminish, with healthcare reform. In reality, it is one that has simply transferred to individuals with high-deductible, high co-insurance plans. It is very important that the patient access staff are equipped with knowledge about available payment options and the skills to effectively communicate them to patients. A lump sum figure can sound very different when articulated as a cost spread out over 12 months.  Are your patient access employees trained to work patient assistance programs into the conversation with patients as soon as possible? They should be—it could make the difference on whether a patient schedules treatment at all.  

Here again, staff will need the right tools at hand for such conversations. A comprehensive package of financial clearance tools, both pre- and post-service, will include:

  • Patient responsibility price estimator
  • Patient propensity-to-pay forecast
  • Insurance eligibility and plan specific benefit status
  • Network status (e.g., patient and provider)
  • Information on payment options and patient assistance plans, including charity care and Medicaid coverage (a requirement for nonprofit hospitals under the 501(r) regulations.)
  • Electronic statements and associated messaging

Consistent communication is also helpful in encouraging patients to keep current with payments. This can be aided by text messaging and emails, both of which are available in some financial clearance tools. At a broader level, engaging patients from the beginning with reliably accurate information will do more than most providers realize to establish and maintain a positive relationship with patients. And it’s a given that many of these conversations won’t be easy to have. In just one example, is the front desk prepared to tell patients they are limited to one yearly procedure—a limit they’ve already met? At these times, especially, it is crucial that patient access departments have quick access to information on different payment options.  

 

Scenario Three: Patient surprised by final bill.

 This is somewhat of a trick scenario in that it’s one hospitals want to avoid at all costs. So the strategy is really two-fold: what to do to avoid the situation in the first place, and how to bring it to a halt if it’s happening too frequently.  

As a preventive measure to assure initial estimates line up with the patient’s actual balance after services, the following tools are essential:  

  • Accurate patient estimates
  • Eligibility and benefit confirmation  
  • Preauthorization verification
  • Medical necessity
  • Revenue cycle analytics to spot trends and potentially problematic issues with claims  

If this scenario occurs on a regular basis, definitely take it as a sign to review certain patient access processes. If your patient access department is still determining estimates by poring over spreadsheets and books of payer rules—some of which are surely outdated—it’s time to switch to an automated price estimator tool.  If authorization issues are a common reason behind denials, it’s probably time to look at how much return you’re getting on all the staff time spent working the phones, fax machines and payer portals for authorization status. By contrast, today’s preauthorization automation can retrieve information about a limitless number of claims at once, from multiple payers. This assures hospitals get paid and there are no surprises for patients.

A decrease in claim denials will almost surely be a happy byproduct of strong automated pre-authorization tools, as authorization issues account for 16 percent (The Advisory Board) of denied claims.  

That said, a strong denial management program should be in place, regardless, to avoid billing patients for something the insurer was supposed to pay for. A core function in such a program will include the regular comparison of payment vouchers with actual invoices. Most information systems don’t perform this comparison, but there are automated tools that can be integrated within the systems to do so for countless claims at once. The end output is a list of discrepancies that inform decision-making about which denials to appeal and which ones to write off.  

 

Conclusion

Just as doctors and nurses have to engage and lead patients through difficult discussions about treatment, today’s patient access department is increasingly tasked with educating and communicating complex financial issues with patients. This is not an easy new reality for patients or providers. New tools and approaches, however, can simplify these interactions with clear and accurate information. Most importantly, they can instill a new sense of confidence in patients in their ability to pay for care.