Today, the three major healthcare stakeholders—patients, providers and payers—are frustrated and resentful.
Patients may interact with their doctors for 15 minutes, only to spend an hour or more on the phone with the biller. They don’t understand the many bills coming to them from different directions, and often assume — believing these bills are insurance’s responsibility — they can leave them unpaid.
Providers are frustrated that insurance companies dictate which tests and procedures their patients should have. And when insurers second-guess their diagnoses and treatments, resentment builds.
Payers struggle with incorrectly coded claims, missing prior authorizations and patient confusion about what is and isn’t covered. Payers must also operate in an ever-changing policy environment in which they must always be prepared for new government intervention in the way we pay for healthcare.
Given these complexities, it’s no wonder the relationships among the three parties have become adversarial. Some say the American healthcare system is beyond repair. I don’t agree.
One key to repairing America’s broken healthcare system is improving communication and transparency among all parties. Technology can do both, often stunningly well.
A Breakdown Of Transparency And Communication
When analyzing healthcare’s brokenness, many prominent voices point to issues like our aging population, overtreatment of the elderly, disparities based on social determinants and a focus on disease care rather than “health” — really, preventative — care. Certainly, these factors contribute to dissatisfaction on all sides.
Modern technologies provide myriad solutions for this tangled system, and when taken together, they can clear some of healthcare’s most significant logjams. They can give patients clarity where there is now confusion, and can relieve providers’ anxiety over payments so that they have more time and energy to invest in quality patient care.
Empower Patients To Explore Options
One important change patients must understand is that they can pay less by shopping around for labs and specialists. For instance, MRI scans vary wildly in price. If a provider’s system intends to charge a patient $2,000 for an MRI, the patient could likely find an out-of-network option closer to $500 by simply calling around.
When patients take more control in healthcare decisions, they feel more empowered and less victimized. The first step in this power shift is full transparency about treatment options, medical benefits and prices.
Adopt Patient Pay Estimates
A large source of frustration for patients is the confusion over multiple bills coming in from payers and providers.
In our current system, patients typically receive two separate statements about two weeks after a doctor visit. If more than one provider is involved, patients receive even more statements. These statements tend to have lots of data that don’t always align. This is confusing, often prompting patients to spend hours on the phone with customer service to no avail. Many of these patients never get around to paying, and after six months of sending bills, the provider writes these debts off, affecting both their own revenue and patients’ credit scores.
Patient failure to pay has more to do with a confusing medical payment system than irresponsibility on the part of the patient. The back-and-forth between payers and providers is invisible to patients, and patients typically receive care before knowing how much it’s going to cost. The solution to this problem is the “pre-service” bill, also known as a “patient payment estimation.”
Providers don’t need to take a shot in the dark when getting an estimate to patients. Providers can utilize artificial intelligence and machine learning technologies to calculate an accurate estimate to be presented to the patient in real time or even days before the patient comes into the office. For the provider, the patient pay estimate has the potential to dramatically increase point-of-care payments, improving cash flows and minimizing self-pay write-offs. The patient, when presented with a clear estimate and payment options, is more likely to pay at or prior to point of care.
Some providers mistakenly assume patients will resist the idea of pre-service payment. On the contrary, rather than viewing patient pay estimates and upfront payments as a nuisance or hardship, evidence exists that patients appreciate them. One survey of 1,000 patients found that 90% actually want to see a pre-service price estimate.
Align Primary And Outside Providers
A lack of transparency has also led to patients receiving full-price bills from outside providers — often a specialist or diagnostic lab—that were referred by the primary provider. If no insurance information exists in the patient’s file, the outside provider often automatically bills the patient the full amount. The breakdown occurs when the referring provider—often a hospital—fails to get the insurance information to the outside provider. Further complicating matters, the patient often doesn’t realize it’s the hospital’s responsibility to communicate this information. Finally, because the primary doctor or hospital has ordered the outside service, the partner is obligated to provide it. What a mess!
Technology can address this communication breakdown. By capturing insurance details and making them available to patients and all providers, benefit eligibility and estimates can be made available for patient review at the time of service, no matter which provider they patronize. Again, this clarity means providers have a higher likelihood of getting paid on their claims.
Healthcare Has To Change—And Technology Will Help
Every year, providers end contracts with payers or vice versa, each claiming the other is not acting in the best interests of the patients. Disputes often take months to settle, and during that time, hundreds of thousands of patients can be left without access to care.
American healthcare will improve when transparency and communication improves among patients, providers and payers. Technology has the potential to ease communication and transparency among the three parties so that American healthcare can begin to heal.
About Jaideep Tandon
Jaideep Tandon is Chairman of Infinx Healthcare, a leader in AI-powered, specialist-supported patient access and revenue cycle solutions.