Ensuring Payment Certainty in an Uncertain Payment Environment

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1 in an Uncertain Payment Environment An Experian Health White Paper

2 The financial health of provider organizations depends on collecting every dollar due. Efficient processes and automated workflow to assure accurate and timely payment for healthcare services is vital to the ability of hospitals, health systems and physician practices to provide high levels of care, and successfully compete in today s market. While optimizing payer payments has always been a priority, more recently, as the patient s share of cost-of-care has increased to as much as 40%1, the importance of facilitating patient payments has increased as well. Today s uncertain payment environment is fraught with confusion and frustration on the part of patients dealing with higher premiums, increasing deductibles and the need to shop for healthcare based not just on quality, but also price. The complexity of health plan contracts adds to the uncertainty: National payers make approximately 13,000 payer policy changes a year each, making it more difficult than ever for providers to achieve payment certainty in the payer arena as risk escalates. Boosting financial performance depends on providers helping patients navigate healthcare as consumers, with the need to understand the costs and expectations newly placed upon them. Providers must also work closely with insurers to assure their ability to stay true to their mission and values. Capabilities needed to optimize payments An Experian Health White Paper Page 1

3 Innovation from necessity Technology designed to strengthen relationships with patients and instill accountability among payer partners helps providers run more effectively and efficiently. Newly available tools have been developed in response to the increasing demand for access to information that enables all parties involved to manage the risk now pervading the healthcare system. Patients who previously had little need to understand their cost of care now require personalized, real-time price estimates that detail their financial responsibility. Payers that used to present more straightforward contracts are now introducing agreements with complex terms that are difficult to evaluate manually. Automation is necessary to help providers understand financial implications. Providers now need greater visibility and analysis capabilities to engage with patients, hold payers accountable and streamline operations. 7 ways to add certainty to payment processes Optimizing payments is the hallmark of a financially responsible healthcare organization. Achieving this sort of payment certainty extends beyond the revenue cycle, encompassing relationships with patients and payers, and impacts numerous areas within the hospital, health system or practice, including claims, patient access, IT and legal. Providers that adopt best practices outlined below, including the ability to generate pricing and projections, submit clean claims and negotiate favorable contracts, maximize revenue, minimize write-offs, and overall, enhance their performance Employing these best practices Automate pricing processes. Leverage chargemaster data, claims history, payers contract terms and patient benefits information. Generate clear, real-time price estimates. Present pricing information to patients before or at the point-ofservice. enables providers to Eliminate manual processes Generate price estimates and revenue projections easily, consistently Increase accurate upfront collections Enhance patients ability to make informed decisions about their care An Experian Health White Paper Page 2

4 Provide patients with a self-service online portal. Give them the ability to actively monitor care, make payments, set up payment plans, add/combine accounts and more. Analyze claims for completeness and accuracy. Review each claim to ensure it is coded properly and contains correct information. Audit payer contract performance continuously. Verify contractually allowed amounts for all claims, and monitor contract terms compliance. Model implications of proposed contracts. Understand how prospective terms will affect payment and financial performance. Adopt a transparency mindset. Assure the organization and patients have access to all information needed to confidently manage financials. Change behaviors and motivate patients to make timely payments Improve collection of patient payments Minimize billing, customer service costs Increase patient satisfaction Prevent denials, avoid claims rework Eliminate undercharging Speed reimbursement Validate reimbursement accuracy and compare expected-to-actual payment Identify and recover underpayments Determine unfavorable terms Develop smart negotiation strategies Compare competing contracts Improve financial performance Strengthen the patient/ provider relationship Most providers have hundreds of contracts with different payers, and the payment methods vary considerably 95% of patients say it s important to know the total cost of a medical procedure up-front.2 96% of patients want to understand their payment options before receiving medical care.3 An Experian Health White Paper Page 3

5 Developing a transparency mindset Achieving payment certainty in a healthcare environment characterized by continual change and increasing risk requires that providers make transparency part of their DNA. An open approach to information access helps assure organizations meet their responsibility to collect all money owed and stay financially viable long term. Right from the start Payment certainty involves implementing patient payment processes early in the revenue cycle. Tools embedded upfront in the workflow assure patients get the timely pricing information they need to plan for their payments, including ways to pay (including payment plans) that increase probability to collect. All-encompassing The need for readily available information on payer reimbursement levels for services is an important part of the transparency equation. Assuring terms are adhered to and contracts are properly negotiated helps providers achieve desired payment certainty. Data security Providers need for transparency must be balanced with the need to maintain privacy and security of patient information and to support the free market price negotiations between health plans and providers. Avoiding unintended consequences of transparency requires trusted data management capabilities and diligent security protocol. An Experian Health White Paper Page 4

6 Conclusion Making sure no money is left on the table while upholding a commitment to patient care and community benefit is a tall order. With the right transparency mindset supported by technology, automation and process all provider objectives can be accomplished with certainty. Sources 1 Rising Self-Pay: Causes & Effects, Capio Partners, from RisingSelfPay.pdf 2 and 3 Leveraging IRS 501(r) Rules to Financially Engage All Patients, HFMA, from aspx?id= Experian Information Solutions, Inc. All rights reserved Experian and the Experian marks used herein are service marks or registered trademarks of Experian Information Solutions, Inc. Other product and company names mentioned herein are the property of their respective owners. An Experian Health White Paper Page 5