Not-So-Balanced Billing

“Out of network.”

According to a report in the New England Journal of Medicine, “one in every five emergency room visits across the country results in a surprise medical bill.”

As evidenced by the amount of ongoing coverage and pleas for state-mandated action, an alarming number of patients go in for care – emergency or routine – and wind up with a bill of astronomic proportions.

This may be due, in part, to the fact that healthcare literacy has hit an all-time low. Patients are largely unaware of their rights, do not know which entities control their bill or handle their complaints, and 63% go in for care under the often-false assumption that doctors providing services at in-network hospitals are also in network.

Who’s to blame?

While healthcare costs inevitably rise, health insurers are simultaneously shrinking their networks, leaving an overflow that at least one party in the equation becomes responsible for. And despite the ever-present bond between patients and their providers, it often ends up being the providers that are plagued with the ramifications of these unexpected costs.

As the saying goes, we hurt the ones we hold dearest.

Insurers are using this patient dissatisfaction as leverage over the provider, by backing them into a corner until they succumb to the pressure and take a lower reimbursement rate.

In a statement to Dallas News, Dr. Don Read, president of the Texas Medical Association claimed that: “the insurance company is the problem, not the doctor. Doctors are having a harder time getting reimbursed, and the surprise bills open up the possibility of negotiation.”

Jay Kaplan, president of the American College of Emergency Physicians, reaffirmed this notion in a TIME Magazine article, stating that: “insurance companies use their own black box database to determine how much they’re going to repay physicians, and often times, those reimbursement rates are just not enough for doctors to accept them.”

Combatting the balance bill.

In response to the building pressure from dissatisfied patients, state mandates have been popping up across the country. From a ban on balance billing, to a requirement that insurance companies cover all outstanding costs, these pieces of legislation take on a variety of approaches.

For instance, Texas – a state where the number of patients who received a surprise bill is more prevalent than those who have not – implemented a mediation system to force payors and providers to settle the outstanding charges, so that the patient is not responsible. However, despite there being about 250,000 Texans with mediation-eligible health plans that received an out-of-network bill in the past two years, less than 4,000 patients have actually used the services to avoid paying for the higher costs of out-of-network care.

On the other end of the spectrum, patients in California are protected from the woes of balance billing through state-mandated legislation. The parameters of these mandates include a ban on balance billing for emergency procedures and a provision where patients receiving care at an in-network facility only have to pay for in-network cost sharing. The exception to this mandate is that self-insured employer health plans are excluded, due to the federal Employee Retirement Income Security Act.

So what can providers do to minimize the pain?

Until we see more state and/or federal legislation to combat unexpected medical costs, here are a few measures that providers can take:

  1. Improve transparency around out-of-network situations and charges. It’s important to communicate with your patients early and often. You may even consider adding a step in the care process to ensure that patients are aware of what’s in and out of network for their health plan. And if it’s feasible, try to provide an estimate of the additional costs on a case-by-case basis, along with any information about in-network alternatives.
  2. Provide patients with payment options. Nearly one in four people say they or someone in their home have had difficulties paying their medical bills in the past year. One third of these patients say the problem stemmed from surprise out-of-network care. Providing patients with a few payment options may help to alleviate the stress of trying to pay off these large medical expenses, which can also result in better care outcomes.
  3. Host a benefits forum. Invite local employers and brokers to attend a benefits forum where they can learn about the in and out of network health plan options for your health system, as well as direct contracting, if applicable. Provide them with takeaway materials to give to their employees or clients so that the information can easily be shared.

Interested in learning more? Let’s talk. ReviveHealth is a modern, full-service agency devoted to healthcare, bringing together strategy, creativity, and execution to create great marketing

April 3, 2018
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