CMS’ reworked the Merit-based Incentive Payment System, to simplify reporting requirements for providers in its 2020 Physician Fee Schedule Quality Payment Program Final Rule.Patient billing disputes result in more work for hospital staff and can potentially stand in the way of timely payment for services. However, many organizations are making efforts to avoid or reduce such disagreements.
Here, healthcare leaders shared the efforts being made at their hospital or health system. Read their responses below, presented alphabetically.
Editor’s note: The following responses were lightly edited for length and clarity.
Abigail (Abby) Abongwa
Vice president of revenue cycle for UW Health (Madison, Wis.)
We’re doing the best job we can to provide clarity to [patients] about their estimated out-of-pocket expenses, based on information that they and their health plan provide to us. We have different letter templates that we use when communicating estimates with patients. For example, an in-network patient will receive a slightly different letter than an out-of-network patient. A “shopper” will receive a different letter than an estimate for a “scheduled” patient. In addition, our estimate letters clearly call out the factors that may affect the “accuracy” of the estimated out-of-pocket costs. These factors include, but are not limited to the following:
- Variations to the services and codes listed in the estimate letter
- A patient receives additional services not listed in the letter (i.e. additional labs, appointments, imaging)
- A patient receives care at a different location (some of our outpatient clinics are departments of the hospital and have different charges from clinics that are not a department of the hospital)
- A patient receives healthcare services from us or another healthcare facility between the date that the estimate was created and the patient’s anticipated date of service (i.e. remaining deductible may change)
Another way to reduce the incidence of patient billing disputes is to ensure that all revenue cycle staff who interact with patients (front to back end) are properly educated about organizational policies and practices to ensure consistent messaging to patients. We also partner with our clinic/department managers and providers to ensure that accurate information is being communicated with patients throughout their journey with us.
Chief revenue officer of Presbyterian Healthcare Services (Albuquerque, N.M.)
At Presbyterian, we strive to be proactive and eliminate surprises for our patients and members. With this approach, we can reduce stress, provide a consistent positive experience and ensure that our patients and members can focus on what is most important — their health.
We believe that the more information that we can provide to our patients and members in advance, the lower the likelihood of patient billing disputes after care is provided. For example, before they receive scheduled care, we contact patients to verify information, discuss financial obligation and offer cost estimates.
We also focus on providing concise and patient-friendly billing statements. It is important to keep billing statements easy-to-understand and provide just enough detail so that patients understand which dates of service they are being billed for, including how much their insurance paid and how much was left as their cost share.
Shauna Gulley, MD
Senior vice president and chief clinical officer of Centura Health (Centennial, Colo.)
As complex as healthcare billing has become, it is not surprising to see the frustration experienced by patients and their loved ones. All of us within healthcare need to catalyze a movement with simplicity and transparency at the heart of much needed change. Through simplifying benefit design, payment models and even the language we use, we can better inform care providers and consumers about real costs associated with care. And, with increased simplicity, we gain clarity and provide transparency to billing.
For now, providers need to continue to do all they can to decrease total cost of care and to help patients understand how much they could expect to pay out of pocket. Helping patients avoid a “sticker shock” reaction fosters an open dialogue as we keep striving for a larger, industry transformation.
Senior vice president of revenue management and managed care for Catholic Health Services of Long Island (Rockville Centre, N.Y.)
The best way to reduce patient billing disputes involves the development of a streamlined upfront process that includes price transparency and clear and concise communication. To avoid future surprises for the patient the organization must ensure the patient’s insurance is active for the date of service, the patient’s benefit package covers said services, and that any network requirements such as authorization or specialist referrals are in place and accurate. Additionally, the organization should make a good-faith-effort to provide the patient with an accurate estimate of the total cost of care, and educate the patient on how benefits are applied to their specific service. The estimate should be specific about what services are included and make the patient aware of potential additional charges such as physician fees or anesthesia. The organization should discuss with the patient their propensity to pay and identify if alternative sources of funding or flexible payment options are required. Lastly, for services scheduled in advance, the process should include a second eligibility validation 24 hours before the procedure to ensure that the insurance coverage continues to be in force. In cases when there is a lapse in coverage, alternative coverage information can be requested of patient.
Jim M. Meyers
System vice president of revenue cycle for Norton Healthcare (Louisville, Ky.)
Reducing patient billing disputes begins with setting expectations with patients on the front end by outlining what their financial responsibility will be. Heath systems do the best they can to estimate a patient’s out-of-pocket expenses with the insurance information a patient provides. However, we highly encourage patients to reach out directly to their insurance carrier to more fully understand their benefits, provide any additional information the insurance company may need, and get a more accurate picture of what their financial obligation will be.
We recommend patients promptly contact their provider’s customer service department with questions or concerns regarding statements, letters or telephone calls. It’s important that they do not ignore the communication but work with their provider’s office for any needed clarification. Customer service representatives are there to help.
Finally, patients should know that there are options available to them if they are having difficulty paying for their medical care. Most healthcare systems provide multiple avenues to financially assist patients, including financial assistance, payment plans, no-interest bank loan programs and Medicaid application assistance.
Executive vice president and chief business strategy officer of Northwell Health (New Hyde Park, N.Y.)
Many patient billing disputes are related to either a lack of or a misunderstanding of insurance benefit plan design, particularly regarding cost sharing. We find that many patients either don’t understand what the deductibles are or that they may have coinsurance or copayment provisions in their plan, and that leads to, a lot of times, misunderstandings about why amounts are due and payable to the hospital or the physician provider.
The way we’re approaching this is trying to improve communication with patients, trying to improve the education around healthcare financial literacy, and making some technology investments to help to be able to give a better or more accurate estimate to patients in advance of them having a scheduled service or procedure.
Over the last year we’ve added about 15 additional financial counselors across our health system. We’re now up to 85. One thing they do is help uninsured or underinsured [patients] qualify for available programs, which could be anything from Medicaid to the New York Essential Plan. We’ll work with patients to explain to them what they will likely qualify for, and then we’ll help them also in the filing process to get the insurance coverage. In addition to that, we help them with estimates either pre-service or point-of-service in terms of what their out-of-pocket costs will be to try to avoid disputes.
We’ve also been investing in staffing up our call center. When an individual patient has a question about their bill, they call a centralized call center. And we’ve been investing in more call center agents and working on improving the training and education of those call center agents so they can better serve our patients.
For the last year or so we’ve been upgrading and revising our public website, including this year adding a whole series of frequently asked questions and definitions around insurance design. On the technology side, about 10 years ago, we put a cost estimator on our website where consumers could go on, put in the insurance they have and the type of procedure and get a range of the out-of-pocket costs. What we realized is those ranges were getting wider and wider, so we’re in the process right now of implementing new technology that’s going to allow us to go out to the consumer’s health plan and ping that plan electronically to understand what their cost-sharing provisions are and where that consumer is in meeting those obligations. We’re going to be able to do that electronically by the end of this year with our physician group and then the early part of next year for our hospitals. Then toward the latter part of next year we’re going to integrate that same technology into our website so there will be a consumer self-service option to do that online and be able to go out to their insurance company and get that information electronically through our website.
David Rich, MD
Chief medical information officer for WVU Medicine (Morgantown, W. Va.)
Explain billing practices up front in a way that patients can understand.
“You will be charged a facility fee and a provider fee for this visit…”
“Your wellness is free, but you may incur a charge for this…”
“You are out of network, so you will pay this much for services.”
In retail, we know prices before we buy. While it is sometimes impossible in healthcare to know what the patient will need upfront, there are many times, at least in the outpatient and procedural settings where we do know that information.
CFO of UCHealth (Aurora, Colo.)
UCHealth’s focus on providing an excellent experience for our patients includes increasing transparency in the insurance and billing process. Real-time authorizations help to eliminate surprise billing. As we provide accurate estimates for patients and expectations of what a bill will be, patients are able to have a choice. Our healthcare system offers one of the nation’s most advanced price estimates tools that provides individualized out-of-pocket expense estimates for numerous services that are specific to patients’ own insurance situations via our online patient portal, mobile app and through a dedicated call center. UCHealth continues to increase the number of services that are available for which to seek estimates. This innovative tool gives patients the power to make informed healthcare choices, assists in guiding them as they select an insurance plan that’s right for them, and helps them understand and plan for their out-of-pocket expenses for healthcare.
Vice president of revenue cycle transformation for Piedmont Healthcare (Atlanta)
The best way to mitigate the risk of a billing dispute is to ensure the patient knows their benefits and expected out of pocket costs for the services they are receiving prior to service. At Piedmont Healthcare, this is done through ensuring we have an accurate order for the service that will be performed as well as the correct insurance information. Whenever possible our team members leverage this information to identify the patient’s expected liabilities through an estimate and then communicates this information to the patient during scheduling, pre-registration, and/or at the time of registration.