In this episode, we are joined by Gordon Jaye, Vice President of Hospital Operations at PatientMatters, to discuss how providers can take the surprise out of medical billing and improve the patient experience.
Highlights of this episode include:
- Background on why surprise medical billing happens, particularly for patients with insurance.
- A review of current legislative efforts to keep surprise billing in check.
- How COVID-19 has provided challenges to both patients and providers.
- What providers can do to take the surprise out of their medical billing.
- What technology is available for providers to educate patients at the front end of their experience about medical billing?
- And more…
Mike Passanante: Hi, this is Mike Passanante and welcome back to the award-winning Hospital Finance Podcast®. Surprise medical bills are an area of great concern for patients and providers, drawing the attention of both federal and state governments. Providers have an opportunity to take a proactive approach that takes the surprise out of billing and improves the patient experience. Joining me to discuss how to do that is Gordon Jaye, Vice President of Hospital Operations at PatientMatters. Gordon, welcome to the show.
Gordon Jaye: Thanks for having me, Mike. Happy to be here.
Mike: Gordon, why don’t you start out by telling us why surprise medical bills happen, particularly for individuals that already have insurance?
Gordon: Sure. So there are many ways a surprise bill could occur. So it occurs if you have a scheduled service, if you have an emergency, or even if you have a non-emergent service. So picture yourself, you’re driving, you’re doing your morning commute, and you get into a fender bender, and it’s nothing serious. You call your hospital because you’ve got some aches, maybe scrapes and bruises, and you want to have it looked at. There is an emergency room not too far from where you are, and the hospital is a participating member in your plan which is great. You’re like, “Okay, I can head on over to the emergency room.” You go there, get your care. You’ve already met your copays and your deductibles. You pay the copay in person, you’ve met your deductible, you assume that whatever the cost of that care will be from that episode will be covered by your payor. What you don’t realize is that behind the scenes, there may be other providers working for the hospital for which your payor is not a provider that may deem you as a out-of-network patient. So while the hospital is a care provider in-network, the provider is behind the scenes, some of them that may have participated in your care, may not be. So a few months go by and you get a nasty reminder in the mail that you have a bill due. And so there hence the surprise. Surprise that you have a bill that’s relevant to the care you received but you were not under the impression that you would owe anything beyond your copay and the deductible that you had already met. So that’s one, just a very easy example of it. Another is you go to your normal provider, your day-to-day primary care physician. The physician refers you for some testing at a local hospital and you assume that the local hospital is part of your plan and you go through the motions and then that too can result in a non-covered at a in-network service. So it’s not the entirety of your visit is not covered, it’s just that part of your visit may not be covered because you are receiving care by a provider in a inpatient– I mean, rather, a in-network hospital but by a non-participating provider. So surprise bills, I think a lot of folks assume that it only happens when you have emergent care when you end up in an emergency room, but it actually can happen fairly routinely because providers typically will refer you to a hospital that they’re most familiar with for your daily care as well.
Mike: That’s a great explanation, Gordon. Let me ask you, what types of legislative efforts are underway to curb surprise billing?
Gordon: So there have been federal level. The House was engaged in some legislation. There are some states that provide very robust comprehensive prevention of surprise billing. And those are typically northeastern states. You have some western states as well. But mostly, in the south, the Midwest, the upper north, you do have states that don’t provide as comprehensive surprise bill legislation, or none at all. Recently, this year, which was– it’s been fraught with all kinds of problems with COVID. The Trump administration did come out with some legislation– or a executive order rather, that requires every provider that is a CMS participating Medicare-Medicaid providing hospital, or entity, for them to provide some price transparency going forward as of January 1st, 2021. Now, price transparency is a good start. It will advise the patient what their out-of-pocket cost is going to be. It does require providers and hospitals to post their charges and what is a covered service as defined by CMS onto their website. They are required to have a downloadable file that someone can consume into a electronic system. Most hospitals are investing in technologies that will allow them to have a patient-facing price estimation tool where I can go online under the hospital’s website and do some self-service. But that’s just a start. That doesn’t account for any type of providers that may be hidden behind a service. So, for example, I may get scheduled for surgery at a participating hospital. The hospital checks my benefits. It’s great. I am a covered member. They give me an estimate, but they give me the estimate for charges that are related to the hospital and not necessarily all the providers that will be associated with my care. And few months go by, I get another bill in the mail, and I find out that the anesthesiologist that participated in my care is not a provider that’s deemed to be in network by my payer. So you have a surprise bill situation. In legislation, it shifts the burden from the patient, knowing preemptively if all of those providers are participating physicians in their plan, to the hospital and the payer. So the payers are required to post consumer-friendly information on their website. So prior to me presenting to surgery, I could go online and identify all those providers that may participate in my care to see if any one of them could result in a surprise bill. Similarly, hospitals are required to do the same as well. So if I have a service that scheduled, a hospital would have to identify for me all the providers that would participate in my care. So to then for me to deem necessary if the information is not what I’ve desired. So what that means is basically the nutshell is that as a consumer, I am then empowered to make a decision, “Do I really want to proceed with this care at this facility, or should I look for a different facility that has coverage for all of those that are participating in my care?” So, as I stated, there are some states, few states but still some states, that provide comprehensive surprise bill rules. And then there are many states that don’t have any, mostly in the south and upper midwest. And then, some that have a collection of rules that are tilted towards the patient but not very comprehensive.
Mike: Gordan, a couple of minutes ago, you mentioned COVID. And I wanted to ask you, has the pandemic exacerbated surprise billing? Have there been any effects on patients or providers?
Gordon: And so COVID provides a lot of challenges as we all know in our day to day life, and unfortunately surprising, but it’s another area where COVID has made an impact and not in a good way. The original CARES Act, which I believe, was signed into the law back in March this year does have some direction and some relief for providers to provide care for COVID-related diagnosis and testing. Authorization rules around those vary from payer to payer. Some payers are requiring some documentation from the physician once a test is performed and a care plan has been developed. And then there are some payers that are changing no rules around COVID or any other diagnosis, that whatever the requirements were for prior authorization and notification of admissions, etc. they still remain in place. And then, you have some that as soon as you are diagnosed with COVID, any resulting care from that point on, as it relates directly to COVID, is covered as part of your plan, and no prior authorization is required. So it is, unfortunately, a collection of loose rules. And they vary from payer to payer. As we all know, authorization is a sticking point on a good day in a hospital. So you do have some challenges there. And then you add the complexities of COVID on top of that where hospitals and providers have had to have cut back staff because either they came down with COVID or they were around with someone with COVID. Or simply for financial reasons, they have reduced their staff. And as soon as you reduce staffing, then it also creates yet another burden on that very labor-intensive process of getting prior authorization. And if you don’t have technology in place to do that, it can take quite a good amount of time to get a authorization obtained. And that’s pre-COVID, during COVID, and, undoubtedly, will be post-COVID as well, whatever that may be. But those challenges remain. And COVID simply complicates the surprise bill arena because of shortages of staff, triaged protocols, care gaps for conditions, all those things that can result in you, unfortunately, presenting to a out-of-network facility. So all of those put together can be a very difficult task to undertake on a good day. And then COVID makes it worse.
Mike: So, given these complexities, how can providers take the surprise out of their medical billing?
Gordon: So the first thing is to educate your patients. Whether you’re using technology or not, understand what the patient’s insurance plan actually covers. Now you do have– the consumer has some burdens on them as well. After all, we, as consumers, have signed up for these insurance plans without any participation from our providers. But we do place a tremendous amount of burden on the provider community to identify for us facilities that will cover us as a in-network facility. So there is some burden on providers. But the burden is equally on the consumer as well. We don’t want to– I certainly we don’t want to give the impression that the consumer should not engage in some self-service and research prior to presenting for non-emergent care. Facilities do invest in lots of technologies. They do invest in patient education, various marketing campaigns. So it is critical for hospitals and providers to engage their patients fairly, help them understand what is a covered service, what may potentially result in a provider being out of network, and really empower your patients with an explanation of their benefits, the urgency of their care, how to do some price shopping. Is the care going to be any different at hospital A versus hospital B so that consumers can make a good decision. And it’s really about understanding the nuances of your insurance plan and winning down. If you have questions as a consumer, I think the first thing to do is call your insurance plan. Find out from them. Let them know that you are about to enter into a hospital and identify which it is and ask them– what is the likelihood of my care being fully covered according to plan guidelines? Or will it result in some type of a surprise bill. The payers are really the gatekeepers of that information and hospitals and providers can help facilitate that education for the patient, but the burden is equally on the consumer as well.
Mike: As you mentioned a minute ago engaging with patients at the front end of their experience is a helpful way to take the surprise out of billing. What are some specific strategies providers can use at that stage?
Gordon: So there is a lot of good technology available on the market that can help providers educate their patients. If you are using technology it certainly makes that work less burdensome for your staff and for your patients. One of the key things is to invest in technologies that provide you real-time benefits explanations so that you are dealing with a patient’s insurance in real time and not something that is pulled from a website that may not be updated as frequently. So you want to look at the patient’s benefits. You certainly want to look to see how much of their deductibles have already been met. Is the deductible applicable to the individual or to the family? What types of other facilities may be able to facilitate this patient’s care at a lower rate? What is the patient’s urgency of care? All of these things can help drive the patient to the right location for the least amount of out-of-pocket costs. I mean, we are now unfortunately living in a world where all of us have some level of deductible. I recall when I was a teenager working for a hospital answering phones. We had a great plan which covered everything, and nowadays everybody has some level of co-pays and deductibles and co-insurances, and all of these terminologies that we all like to throw around, makes sense to us. Those of us who work in health care day in day out, but for our patient population that is not the case. Do they truly understand cost sharing versus a deductible or a co-pay against a co-insurance? So what are some of the nuances of that? Helping them understand what their true out-of-pocket cost is going to be, and then using all of that information and creating a customized solution for the patient using price estimation, using the patient’s ability and propensity to pay, helping identify additional payer sources. If a patient is uninsured, what are some of the ways we can help either get the patient coverage, or is the patient a candidate for your charity program? So there are so many ways that we can educate the patient ahead of service, provide them a path forward that meets all of their care needs but also provide them a financial path forward. If you do have coverage, which is great if you do, but if you do have coverage you may have a high deductible plan that doesn’t cover services beyond X number of dollars for that service, and you may still feel like a uninsured patient because your your co-pays and deductibles and coverages are so slim. And for those types of patients they still may have a very large out-of-pocket cost share on their plan. And so then providing the patient a path forward by defining some of the terms of payments. Perhaps you can pre pre-emptively engage the patient in a payment plan and help enroll them into that so that when the bill does arrive they don’t have this mental stress of figuring out how it is that they will pay that very large bill. So all of that to say there are technologies available on the front end but similarly you also have to provide patient education which is very, very much dependent on a facility’s ability to have staff in place that understand each of these plans and then provide a patient a good path forward.
Mike: Gordan, if someone wanted to learn more about you or patient matters where can they go?
Gordon: So for patient matters they can go to www.patientmatters.com. If you go to our news and events section, there are a bunch of webinars and news releases that we place quite frequently. There is a module that is dedicated to the financial impacts of surprise bills so if they want to learn more about that topic they can certainly go to that site. For me as well, they can go to either patientmatters.com or they can find me on LinkedIn. Feel free to send me a direct message there. Or they can email me directly at Gordon.Jaye@patientmatters.com
Mike: Gordon Jaye, thank you for stopping by the hospital finance podcast today, and helping us all understand how to take the surprise out of medical billing.
Gordon: Thank you, Mike. Have a good day.