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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 unexpected balances the patient owes. This can occur for example when a patient receives care from a hospital that is in-network but 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 idea the clinicians who treat them are out-of-network, and the balance bills can be exceedingly high.

In fact, examples of anesthesia and pathology balance bills exceeding $20,000 have been cited in legislative hearings.1

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, as an industry we are seeing an increase in self-pay patients — uninsured patients that do not qualify for charitable programs or state Medicaid programs. Self-pay patients take longer to pay and 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 percent were for independent lab testing.

For these reasons plus the increase in high-deductible insurance plans and limits on coverage through employer-sponsored plans, patients are experiencing much higher out-of-pocket costs. Even typical American families with good commercial health insurance coverage are 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 this issue, XIFIN, Inc. developed a patient responsibility estimator, a sophisticated estimator that uniquely leverages the important data required to more accurately calculate the forecast of patient responsibility. XIFIN RPM therefore creates a much more precise patient responsibility estimate. By providing patients with real-time estimates of their portion due, diagnostic providers and remote patient monitoring companies can vastly increase the potential for collecting at or before the time of service. Email notifications are sent to patients when their patient responsibility estimations are ready to be viewed.

Learn more about our Patient Estimator in this video.

Accessible through the XIFIN RPM client portal interface or patient service center (PSC), the patient responsibility estimator can also be made available directly to patients via the provider’s website. And, XIFIN’s newest text functionality 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 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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Published by XIFIN
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