Patient experience is currently a high priority for healthcare leaders – not to mention regulators – and organizations are focused on initiatives to improve price transparency, accurately estimate patients’ out-of-pocket expenses, and prevent surprise billing.
There will be multiple bills aimed at protecting patients from surprise billing presented to Congress as it begins its 2020 legislative session. Thus, the balance between protecting patients and paying providers will be top of mind as pressure from both sides is rising.
Recently, several medical specialty societies—such as the American Medical Association and the American College of Emergency Physicians – submitted a coalition letter to the U.S. House Ways and Means Committee and the House Committee on Education and Labor, offering a solution to protect patients by providing interim payment to healthcare providers while arbitration is performed. Click here for more details. This is one of several bills expected to be reviewed in 2020.
In the past, it was more common for patients to be surprised by separate bills from doctors who were out-of-network, on top of their in-network hospital bill. These services, rendered in an in-network facility, created larger amounts due for unsuspecting patients who assumed an in-network facility would have in-network providers and services. Although healthcare organizations have made strides over the years to ensure these situations are identified and limited by creating better contracting agreements, surprise billing continues to happen today. These surprise bills reflect poorly on an organization if patients are not made aware and provided alternative options for care in advance.
Tina Williams is a principal consultant with HBI. She received her master’s degree in Healthcare Management from Vanderbilt’s Owen Graduate School of Management. In the following Q&A, Williams describes the risk of surprise billing from third-party providers and provides her perspective on precautions organizations can take to ensure a positive patient experience.
Why do providers need to find solutions or ways to address surprise billing?
Williams: As we move into the age of consumerism in healthcare, more and more people are going to shop around using social media and ratings to select where to receive care. Similarly, as organizations get more sophisticated with price transparency, identifying third-party providers or services that do not fall within their control, but are commonly prescribed by their providers, will be essential in meeting the patients’ expectations around financial transparency. If organizations fail to provide such information, it is likely that patients will go to social media to voice their dissatisfaction. It is also likely this type of negative patient experience will be reflected in surveys that determine the organizations’ ratings, thus affecting their overall reputation and financial stability.
In what situations can surprise billing occur?
Williams: Surprise billing may occur when a patient seeks emergency care at an in-network facility that contracts with ED doctors who are out-of-network. Another example would be when an in-network provider unknowingly prescribes services from an out-of-network provider, and is unaware of the negative financial implications for the patient on the back end.
I personally received a surprise bill for a recent surgery due to a monitoring service my surgeon routinely orders during care, which was not pre-authorized and was denied. Although this denial may be overturned once medical records are submitted, the initial explanation of benefits shows I am financially responsible. Since my relationship is not with this monitoring service, whom I didn’t know existed, the dissatisfaction I had was with my surgeon and his office. Especially since this monitoring service is routinely ordered, but was not discussed during scheduling, and charges exceeded the charges for the surgeon himself.
When surprise billing occurs, the patient is not going to reach out to a third-party provider they do not recognize, they are going to call their doctor’s office or hospital where they went for treatment. In my situation, I expected my provider’s office to tell me about the monitoring, provide me with information, and let me know prior to surgery so that I could ensure it would be covered. If there were issues with coverage I would expect to have the opportunity to discuss other options with my doctor prior to surgery.
Right or wrong, the patient, even a patient in the healthcare industry, expects the ordering provider to tell them where the “land mines” are.
What can providers do to prevent this type of surprise billing from happening?
Williams: Physician practices and hospitals must be more proactive when contracting with third parties, to consider the out-of-network implications to their patients. When a decision is made to contract with third-party providers, regardless of the network, it is important to ensure the patient is aware of the services being ordered or rendered, and why they are necessary. The ordering physician or staff should provide information on the services and what to expect from those third parties by way of billing, authorizations, and out-of-pocket expense. Obtaining printed materials or fact sheets is a great way to place the onus on the patient to follow up with the out-of-network provider to understand their liability and to discuss any alternative options with their in-network provider. This only works if the provider or hospital communicates with the patient prior to service, or in cases of emergency services, at the time of service.
Creating a correlation to calls made to provider offices regarding surprise bills from third parties to the provider and their staff is another way to prevent dissatisfied patients. Tracking patient calls regarding services being ordered by third parties can alert the ordering physician and allow them to make alternative decisions, or at the very least provide his or her front-line staff with the information necessary to inform the patient. Tracking these calls and using data to make informed decisions can make a huge impact on reducing surprise billing.
What is an example of how an organization can communicate better with patients about contracted third parties?
Williams: This past summer I had a procedure scheduled by my ophthalmologist. I chose to go to a satellite eye center near my home that was part of my healthcare organization. During scheduling, I was told, “The nearby surgery center the doctor uses is not part of our organization. Someone from the surgery center will be contacting you to discuss the status of the authorization and provide you with an out-of-pocket estimate. We will get the authorization, but they will let you know whether they‘re surgery center is in-network and how much they estimate you will owe. Depending on your insurance response you may decide to have your procedure at our main campus where you know you’re in-network. Please contact our office if you have any questions or wish to change locations.”
The scheduler also gave me a fact sheet about the surgery center which included contact information. She told me if I had not heard from them in three or four days to call them to check on the status.
That‘s an example of a proactive approach, because they know that surgery center is not part of their healthcare organization, they’re educating the patient to let them know what they need to do, and allowing the patient to make an informed decision.
That’s where we, the healthcare industry, have an opportunity to make a difference in advocating for our patients. Gone are the days when we do not have to worry about coverage for care that we are ordering outside of our own control. If we are going to ensure patient satisfaction and truly provide transparency, we will have to make this part of our responsibility moving forward.
Do you want to have access to more expert insights on surprise billing, price transparency, and patient consumerism? Fill out the form below to learn how HBI can help you improve your patient experience.