What is Price Transparency?
It’s a story we hear too often. A person visits a hospital for a medical issue—whether it be a trip to the emergency room for a broken arm or a pre-scheduled appointment for a headache that just won’t go away—and receives a myriad of services and tests. Then comes the dreaded bill in the mail a few weeks later. Although they may inquire about an estimate at the time of service or have an idea of their coverage, the exact financial responsibility is often a mystery until that bill arrives. While the changes vary greatly, one thing that is certain: many people have trouble with their out-of-pocket costs. So much so that a recent survey from The Commonwealth Fund found that 72 million Americans have some sort of trouble with medical debt.
So, on January 1, 2021, the price transparency rule was put into effect—from the Centers for Medicare and Medicaid Services (CMS)—requiring all hospitals within the United States hospitals to publish the prices of various medical procedures. In particular, standard charges for services and items must be published online, available for patients to access. Until now, these prices were hard to find. The timing of this change—the beginning of the calendar year—comes at a time when healthcare pricing is top of mind since many customers most likely renewed or changed insurance carriers and coverage on January 1, 2021. With this comes a focus on out-of-pocket costs, deductibles, and more.
What Brought About This Radical Change?
Part of this change can be attributed to the consumers themselves. With the increase in high deductible health plans and increased out-of-pocket costs, finances are top of mind. In addition to these factors, today’s consumers demand a better overall patient experience. With the prevalence of online shopping, patients expect the same seamless transaction at the hospital that they receive with companies like Amazon, Walmart, and Home Depot. Just as consumers read product reviews before placing an item in their online shopping cart, patients research services and access peer reviews of physicians before they go to the office. In short, they want to be knowledgeable about their healthcare and crave tailored services with exceptional customer service.
Many believe this change will be well received, with Forbes calling the ruling a “gift to all Americans.” From the consumer’s standpoint, it will now be easier to make educated decisions based on cost. This will then cut down on the “unknown”—hopefully eliminating those hefty surprise bills—and opens the door to comparison shopping. Advocates are hoping this newfound transparency will eventually lower costs, with the competition eventually driving down the prices.
How Can Healthcare Organizations Navigate This Change?
This will not only promote transparency but will also increase convenience. By enabling patients to access and pay their bills on their own schedule with easy-to-implement solutions, organizations are meeting them halfway, so to speak. With easy-to-understand statements, integrated credit card processing, and 24/7 payment portals, it is no longer a hassle to manage medical financials. For healthcare organizations, facilitating proactive management of a person’s cost of care accelerates revenue collections and patient satisfaction improves.
In the larger sense, executives recognize that patients are taking more stock in their personal care. In order to thrive, hospitals and health systems must work toward creating the optimal patient experience, beyond just price transparency. With this, providers should aim to be more engaged and C-suite executives should try to provide additional benefits to their patients.
What Will This Mean for the Future of the Industry?
Only time will tell what the price transparency will mean for the industry. However, it is safe to say that this concept has the possibility to shape healthcare policies and processes for years to come.
So, for more information on solutions that equip you to have informed conversations about eligibility and financial responsibility, contact one of EZClaim’s partners, TriZetto Provider Solutions, to talk with one of their representatives today.
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, e-mail them, or call them today at 877.650.0904.
[ Article contributed by TriZetto Provider Solutions Editorial Team ]
There are five ‘phases’ in the life cycle of a medical bill: Pre-appointment; Point of care; Claim submission; Insurance payment or denial; and Patient payment. This post will overview each of these phases, and could even be considered to be a “101-level” course on Revenue Cycle Management.
With high deductible health plans on the rise, the recent explosion of telehealth appointments due to COVID-19, and many other factors in play, it’s more important than ever for everyone to understand the life cycle of a medical bill, and how the process works. The healthcare revenue cycle is relevant not only to those who work in healthcare, but to the patient, too.
The revenue cycle is the series of processes around healthcare payments—from the time a patient makes an appointment to the time a provider is paid—and everything in between. One way to think of it is in terms of the life cycle of a medical bill. Although there are many ways this process can play out, this post will lay out a common example below:
For most general care, the first stage of the revenue cycle begins when a patient contacts a provider to set up their appointment. Generally this is when relevant patient information will begin to be collected for the eventual bill, referred to on the financial side of healthcare as a claim.
At this point a provider will determine whether the appointment and procedure will need prior authorization from an insurance company (referred to as the payer). Also, the electronic health record (EHR) used to help generate the claim is created, and will begin to accumulate further detail as the provider sends an eligibility inquiry to check into the patient’s insurance coverage.
2. Point of care
The next step in the process begins when the patient arrives for their appointment. This could include when a patient arrives for an initial consultation, an outpatient procedure, or for a follow-up exam. This could also include a Telehealth appointment.
At any of these events, the provider may charge an up-front cost. One example of this is a co-pay, which is the set amount patients pay after their deductible (if they are insured), however, there are other kinds of payments that fall into this category, too.
3. Claim submission
After the point of care, the provider completes and submits a claim with the appropriate codes to the payer. In order to accomplish that, billing staff must collect all necessary documentation and attach it to the claim. After submitting the claim to the payer, the provider’s team will monitor whether a claim has been been accepted, rejected, or denied.
[ Note: Medical coding refers to the clerical process of translating steps in the patient experience with reference numbers. The codes are normally based on medical documentation, such as a doctor’s notes or laboratory results. These explain to a payer how a patient was diagnosed and treated, and why. This information helps the payer decide how much of an encounter is covered under any given insurance plan, and therefore how much the payer will pay. ]
4. Insurance payment or denial
Once the payer receives the claim, they ensure it contains complete information and agrees with provider and patient records. If there is an error, the claim will be rejected outright and the provider will have to submit a corrected claim.
The payer then begins the review process, referred to as adjudication. Payers evaluate claims for accurate coding and documentation, medical necessity, appropriate authorization, and more. Through this process, the payer decides their financial obligation. Any factor could cause the payer to deny the claim.
If the claim is approved, the payer submits payment to the provider with information explaining details of their decision. If the claim is denied, the provider will need to determine if the original needs to be corrected, or if it makes more sense to appeal the payer’s decision.
Following adjudication, the payer will send an explanation of benefits (EOB) to the patient. This EOB will provide a breakdown of how the patient’s coverage matched up to the charges attached to their care. It is not a billing statement, but it does show what the provider charged the payer, what portion insurance covers, and how much the patient is responsible for.
5. Patient payment
The next phase occurs when the provider sends the patient a statement for their portion of financial responsibility. This stage occurs once the provider and payer have agreed on the details of the claim, what has been paid, and what is still owed.
The last step occurs when a patient pays the balance that they owe the provider for their care. Depending on the amount, the patient may be able pay it all at once, or they might need to work with the provider on a payment plan.
The above example represents one way the lie cycle of a medical bill can play out. Some of the ‘phases’ are often repeated. Because of the complexity of healthcare payments and the parties involved, there is not always a ‘straight line’ from patient care to complete payment. That’s why we call it the revenue cycle, and there are companies that provide systems for its management.
One of EZClaim’s partners, Waystar, aims to simplify and unify healthcare payments. Their technology automates many parts of the billing process laid out above, so it takes less time and energy for providers and their teams, and is more transparent for patients (Click here to learn more about how Waystar automates manual tasks and streamlines workflows.) When the revenue cycle is operating at its most efficient, providers can focus their resources on improving patient care—and that’s a better way forward for everyone!
For more information of how Waystar works together with EZClaim, click here.
[ Article and image provided by Waystar ]
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support, and can help improve medical billing revenues. To learn more, visit their website, e-mail them at firstname.lastname@example.org, or call a representative today at 877.650.0904.