One of the biggest issues in healthcare cost today is providing patients with an accurate estimate of their cost. In today’s world of changing healthcare regulations, complicated contracts, a lack of data or incorrect patient data, and more, it’s not surprising that providers can be just as confused as patients.
Today’s healthcare system lacks a standardization of treatment and billing protocols, which ultimately delivers estimates that don’t come with a guarantee of price or an assurance of outcome.
This is especially true in the insurance arena. There are times when patients simply don’t know what their health insurance provider will pay or when they will pay out. A standardized billing system would solve many of these issues, but such a thing does not yet exist.
With the non-standard billing system that’s in place today, what can patients, providers, and payers do to make it easier for everyone to know what’s expected of them?
Why Is it Difficult to Estimate Costs?
It’s difficult to accurately estimate costs in today’s healthcare system in part because payers (large commercial insurers) do not share the charge and claims data. Not only has the lack of shared payer data slowed the transition to value-based care, but also create a barrier to future provider-payer cooperation.
Because payers’ claims and health information can provide a more holistic, accurate view of patients’ health issues and provider interactions, it is vital for providers to have greater access.
Health insurance policies are incredibly complex, too, and many patients aren’t sure what their policies will cover or how much they will pay. Another issue is that proposed treatments aren’t always the treatments that are done, causing even more confusion in the billing process.
What can be done to deal with this complex system so that patients can be given an accurate payment estimate?
There are a few different options that may help.
Offering Payment Options
What exactly is a patient’s responsibility in the billing process? This responsibility has never been clearly defined. The provider’s responsibility is to offer different payment options, but it’s not clear what the patient needs to do to access such alternatives or information. This has become less of a vague area in recent years thanks to technology. Aside from providing patients with an explanation of benefits form (EOB), in which insurance companies outline what medical services/treatments were covered on their behalf, the public platform can now access their accounts online in order to view bills and make payments. This has helped simplify the process and create more transparency.
Another solution is to bundle fees. Rather than a patient paying fees to their physician, surgeon, anesthesiologist, and other experts, those fees can be clearly bundled and listed on one bill. This makes it clear to see how much a patient owes and what the insurance provider will be paying. With less paperwork, there are fewer bills to go through, understand, and pay. When there’s one payment to be made, patients are often able to better budget for that payment instead of trying to split their limited financial resources among multiple bills.
However, not all bundles are equal; a retrospective healthcare bundled payment model requires fees to be calculated ahead of time and then reconciled against fee-for-service medical claims. While, ultimately, this retrospective approach will determine shared savings after the episode of care ends, it does little for the patient in regard to decision making, and doesn’t guarantee their end-cost will be reduced.
Define the Patient’s Responsibility
To determine a patient’s financial responsibility, the payer and healthcare provider often look at the patient’s network, coverage level, payments made, procedures scheduled and completed, and their out-of-pocket maximum. Determining what the patient’s insurance covers is not always clear, especially for the patient. One way of simplifying this process is to create digital records. These records can then be shared between payer and patient to clarify what has been paid and what will be paid. Patients are able to access these records whenever they need. This also helps define the patient’s responsibility since they can more easily see what payments they are responsible for making and when those payments are due.
In today’s value-based healthcare system, however, the best patient responsibility is “zero-responsibility.” By presenting employees with value options, not cheap care, but quality assured care from pre-vetted providers offering competitive rates, providers can achieve shared savings with the real stakeholders- their patients.
Why It Matters
If patients don’t have an accurate estimate of the cost of a procedure or medication, it’s possible they simply won’t schedule it. This is why surgery centers, in particular, need to have a system of providing accurate estimates, and more.
Why? It takes more than “good estimates” to protect patients and providers. Transparency isn’t enough; as many estimates are simply estimates, and don’t always hold true to the end. It’s possible some patients will go ahead with the procedure only to realize that it cost much more than they can afford. With unpaid bills putting patients in financial stress, avoiding care, and shifting some of the service costs back onto providers, often, the solution is to raise costs, transferring the lost payment to future patients.
Ultimately, the provider, insurer, and patient need to work together. By making use of the latest technology, it’s possible to provide transparent billing and make what was once a confusing system much simpler and more precise.
One way of doing this is to partner with a company that helps providers become more transparent by guaranteeing fixed prices and clear outcomes. Access Health Net delivers prices that are guaranteed, transparent and actionable, and beneficial to all steak-holders, from provider and patient, to employers and employees. Check out our SuperOption to learn more about how Access Health Net has helped providers serve their patients with top-notch care while keeping their overall costs down.