Dealing with 'under-insured' patients (High Deductible Health Plans)

Advent of High Deductible Health Plans was supposed to help all the concerned parties: employers, patients, insurers and the provider. But we all know now that it primarily benefits the employers and insurers....the healthcare provider essentially got the 'short end of the stick'....

With average annual deductible over $2000 and co-insurance ranging from 10% to 50%, we are talking significant dollars...and providers are now stuck with the added cost of these patient collections and significant increase in exposure to patient bad debt dealing with this new class of 'under-insured' patients.

It was hard as it is to collect money from Insurance companies but at least there was a guarantee of payment (subject to denials of course) but with patient collections..there is no such guarantee. For most patients (including those who you might categorize as 'well-off'), paying doctors bill comes last in their order of priority...No wonder according to one MGMA article, the rate of patient delinquency (post-visit) is as high as 50% in many cases. Also, it is not uncommon to have 6 patient statements go out (costing over 5 bucks at the minimum) even for small balance like $10.00. With patients paying higher percent of healthcare dollars, this problem is only going to get worse...unless a provider prepares to deal with the situation.

It good old days, it was very simple; the patient showed you his Insurance ID card, you collected a small co-pay ($10 -$20) and billed the health plan for the visit...few weeks down the road, you got your money (assuming the claim met insurer's interpretation of 'clean claim'). But with this new class of patients with high deductibles and high co-insurance, unless you can accurately estimate and collect patient obligations at or before the time of service, you are are at risk of losing significant portion of that portion to patient delinquency or to cost of collections.

In order to collect patient obligations at or before the time of visit, Physician's Office first needs to have:

a) Detailed and up-to-date information on patient's coverage and benefits
b) Expected Insurance 'allowable' amount for the services to be rendered

The expected 'allowable' amount can easily be pulled up from any practice management system (or an average amount can be set for common CPTs and procedures)...the hard part is to the detailed and up-to-date coverage and benefits information. This includes:

1) Remaining Deductible (for E & M and for other procedures)
2) Co-insurance (service specific)
3) Co-Pay (specific to your specialty and to the services being performed)

To make things more complicated (and hence more time-consuming), this info can vary by service type...for example E&M codes may have no co-ins and might even be exempted from deductibles in certain plans whereas other procedures might have significant co-insurance and subject to deductible.

Unfortunately, most provider offices do not have enough resources or time to perform thorough verification of benefits...with patients with high-deductible plans accounting of 10% or more in many regions of the U.S, the exposure to potential patient bad-debt is significant.

Some provider offices have tried to automate the process of eligibility verification by either subscribing to online all-payer eligibility vendors or have use Practice Software integrated solutions. But the problem is that HIPAA Eligibility Transaction set (EDI 270/271) does not mandate that this data be contextual (e.g. specialist co-pay versus primary care co-pay) or be complete or consistent across the payers. For example, many commercial payers do not send ‘Deductible Remaining’ information which is critical for determining patient’s obligations. Thus, even after using automation tools, neither the verification is thorough not does it reduce costs.

To solve this problem, pVerify.net Solutions (Irvine, CA) has come out with an innovative solution. 'Full-Service Eligibility™' from pVerify™ GUARANTEES COMPLETE (incl. 'Deductible Remaining' and 'out-of-pocket' info), CONSISTENT and CONTEXTUAL (i.e. Specialist Vs Primary Care) patient eligibility and benefits information across ALL the payers thus facilitating providers to collect 100% of patient obligation payments at the time of service. pVerify provides a 'Patient Payment Estimator' that takes in to consideration the insurance 'allowables' and the patient's benefits to come up with an estimation that the doctor's office can collect as a advance at the time of the visit.

If the provider's office has a good idea of the procedures to be performed (for example, an Imaging Center generally knows the the modalities at the time of appointment), they can collect the money prior to or at the time of check-in. For those providers who may not know the procedures till the doctor has seen the patient, the workflow should be to collect the 'advance' on check-out or patient discharge.

If a particular payer does not provide 'deductible remaining' information, (or in case of a payer which does not support electronic verification at all) pVerify still guarantees this information by seamlessly combining electronic verification with manual, phone-call base means via batch verification process. One added benefit of using pVerify's service is that you can dramatically reduce eligibility related insurance denials (through generation of higher percent of 'clean claims' by detecting errors in patient demographics or IDs).

On average, providers can expect improvement in cash-flow of 20% or more while reducing overhead costs by up to 50%...all adding up to one of the highest ROI (return on investment) of any such solution in the industry.

More about pVerify on: http://www.pverify.net/