How an Accurate Patient Out-of-Pocket Expense Estimator Helps Prevent Surprise Billing

There has been a lot written about surprise billing lately and the No Surprises Act, which includes surprise billing legislation, was signed into law the final week of 2020 and is slated to go into effect on Jan. 1, 2022. Surprise medical bills are bills received by patients with unexpected balances due. This can occur when, for example, a patient receives care from a hospital that is in-network but while there is seen by a clinician that is out-of-network. The subsequent “balance bill” — the difference between what the provider charged and what the payor reimbursed — can be both confusing and frustrating for patients. In most cases patients have no way of knowing that the clinicians who treated them are out-of-network, and these balance bills can be exceedingly high.

While emergency medicine is often the poster child for the most egregious balance bills, the surprise billing law is likely to have an impact on diagnostic provider billing and negotiations with payors as well. At the same time, the healthcare and diagnostics industry is experiencing an increase in self-pay patients — uninsured patients that earn enough to be ineligible for charitable programs or state Medicaid programs, but who nonetheless are financially limited in their ability to pay these surprise bills. In a best-case scenario, self-pay patients take longer to pay. In many cases they have a higher risk of write-off. This adds to the already pervasive financial strain on most independent laboratories and other diagnostic providers.

Approximately 70% of hospital leaders reported expecting to see an increase in self-pay patients due to the impact of the pandemic, according to a Guidehouse Center for Health Insights analysis of a survey conducted by the Healthcare Financial Management Association (HFMA). According to a January 7, 2021 article in 360 Dx, an analysis by the Health Care Cost Institute in 2019 found that of the specialty claims billed as out-of-network during an in-network hospital visit, 22 % were for independent lab testing.

In addition, the increase in high-deductible insurance plans and limits on coverage through many employer-sponsored plans means patients are experiencing much higher out-of-pocket costs. Even typical American families with good commercial health insurance coverage are often struggling to meet their portion of healthcare costs. An accurate understanding of a patient’s financial responsibility is an increasingly important aspect of patient satisfaction.

To address these issues, XiFin, Inc. developed a patient responsibility estimator, a sophisticated application that uniquely leverages the important data required to more accurately calculate the forecast of patient responsibility. This enables XiFin RPM to create a much more precise patient responsibility estimate and make that estimate available through the XiFin RPM patient portal. XiFin RPM sends email notifications to patients when their patient responsibility estimations are ready to be viewed in the portal. By providing patients with real-time estimates of their expected payment due, diagnostic providers and independent device testing facilities (IDTFs) can vastly increase their potential for collecting a partial payment at or before the time of service.

Learn more about our Patient Estimator in this video.

Also accessible through the XiFin RPM client portal or patient service center (PSC), the patient responsibility estimator can alternatively be made available to patients via the provider’s website. XiFin has also introduced text functionality that provides the option of enabling the patient responsibility estimate to be communicated in near real time to the patient via text message. This new capability will notify patients via text message that they can retrieve their estimated out-of-pocket expense, approve to move forward with the test and prepay—all through the patient portal.

An accurate patient responsibility estimator is a vital tool in improving patient engagement and ensuring patients are not blindsided with unexpected costs. Providing price transparency early in the diagnostic ordering process is an excellent way to enhance both the patient and ordering physician experience, as well as to support evolving surprise billing rules and regulations.

An accurate patient responsibility estimator is a vital tool in improving patient engagement and ensuring patients aren’t blindsided with unexpected costs. Providing price transparency early in the ordering process is an excellent way to enhance both the patient and physician experience.

See how Ambry Genetics utilized the patient estimator among other RPM capabilites to improve the patient experience in this case study.

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Sources:

1. https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/health-matters-in-elections/surprise-billing