April 30, 2007

Improving the Patient Billing Experience
By Gregory Richardson
For The Record
Vol. 19 No. 9 P. 8

The patient comes first. This motto was once the golden rule applied by medical practitioners when making key decisions regarding how to provide quality healthcare. Taking proper care of a patient in need of medical attention was considered the priority before ascertaining his or her ability to pay.

In the past, medical billing was less complex—patients paid their doctor’s office directly for medical services. Today, the billing process has evolved along with its participants. Instead of the simple doctor/patient relationship, we now have the government, insurance, doctor/hospital (provider), employer, and patient relationships. In this new, more sophisticated healthcare environment, it is important not to lose sight of patient care.

No patient should ever be left holding a bill they don’t understand. A patient must be able to look at a medical bill and quickly understand the financial obligation. Confusing medical bills cause patients to become frustrated with the healthcare system.

Patients who call a provider’s billing office and must wait on hold for any length of time prior to receiving a billing statement explanation often feel dissatisfied. However, we cannot blame what happens at the doctor’s office for all the problems a patient faces in the healthcare industry. Regulatory requirements, coding requirements, benefit plans, and complex software issues can all contribute to a patient’s negative experience.

There are many ways to improve healthcare billing and create a positive patient experience. Let’s take a look at the players involved and what their roles in the improvement process should be.

Providers
This group bears the burden of improving the billing process for the patient. This is a key touch point for the provider and patient. From its first encounter with the patient, the provider must ensure that the correct patient information is entered into the respective systems. In addition, the provider should provide a clear explanation of the patient’s out-of-pocket expenses. For example, when running a benefits check, the provider must know the patient’s deductible, copays, and whether specific medical services are covered. The provider should advise the patient to contact his or her insurance company to discuss pending care so he or she has a better understanding of what to expect prior to receiving that care.

Providers should inform the patient of their billing process—for example, the insurance will be billed before the patient receives a statement, or the patient will receive a statement at the same time that the insurance is billed. Patients should understand the timeline and be empowered to call the provider or insurance company when the timeline isn’t achieved. This will prevent a delay in notifying patients that they have a much larger bill than what they anticipated.

Providers should make use of current technology that allows them to automatically notify the patient for reminders, etc, as well as allow the patient to review and comment on information without having to wait for the next available representative. How many of us have received statements on a Friday and then worried about the bill over the weekend when there were no answers to be had? That frustration is compounded by many jobs that don’t allow personal phone calls during working hours. By the time the patient actually contacts the provider, he or she is already stressed. Patients who are better prepared up-front and have easy access to understandable data will have a better experience.

Patients
Patients must take responsibility of understanding their health insurance coverage and benefits. Patients should not depend on providers to decipher their plan. When patients take responsibility for making sure that the care and administrative processes are resolved for both the provider and insurance company, they are less likely to receive a bill they don’t understand.

Patients should provide feedback to their provider regarding their bills. For example, patients should note both the clear and confusing aspects of their bill. Patients should also hold their insurance company accountable for its representation of the covered services and how well it complied with its promise.

Employers
Employers should ensure that employees understand their benefits package and how the network operates. As the primary purchaser of healthcare insurance plans, employers need to be more involved in understanding what they are purchasing. If employers push to uncover all the hidden, noninclusive services, there will be less frustration.

Insurance Companies
This sector can improve the billing process by clearly laying out the benefits. Insurance companies, which have contributed to the thousands of diagnosis and procedure codes currently in play, exploit those codes to exclude what they deem expensive care.
Just when you think you understand your plan, you get an unexpected bill from a hospital. The insurance company will stand on statements such as, “Yes, that is a covered service but not with that diagnosis.”

No reasonable person can understand financial obligations under this system. Educated consumers will be better able to translate medical services into out-of-pocket costs.

Federal Government
Washington has an obligation to review the high costs of healthcare. It is not, as many believe, that providers just want to make money. The reimbursement process is flawed and has resulted in complex billing and claims systems. While standards have been put in place for security and privacy, requirements for receiving timely and accurate payments vary by insurance company.

The healthcare relationship is not just between provider and patient. All players must recognize their role in creating today’s complex patient billing environment and work to make it one that puts the patient first in healthcare.

— Gregory Richardson is a consultant with Massachusetts-based Beacon Partners. He can be reached at gregory.richardson@beaconpartners.com.