Practice Management Alert

One payer offers you a new tool that may help you collect from patients.

Rising costs and increased patient payment responsibility is hitting some practices where it hurts -- their income. But some payers, such as Highmark in Pennsylvania, are offering you a tool to help you bring in every dollar.

In today's struggling economy, letting patients know their healthcare costs before your physician provides service can help ensure that you actually collect all the money you-re owed.

Highmark has introduced a real-time tool that will allow billing and collections departments to estimate the cost of services for specific patients. In turn, the hope is that patients will gain a better understanding of their individual payment responsibility and that the tool will allow the practice to set up financial arrangements when necessary. The cost estimation will take into account the individual patient's health plan, including deductibles and coinsurance.

"I think access to a tool like this can greatly benefit a practice and help increase and retain revenue, as well as decrease denials," says Nicole Martin, CPC, compliance auditor for Abington Memorial Hospital in Pennsylvania. "I would expect with proper education and expectations of staff and patients, this tool will be highly successful in decreasing overall A/R and denials."

The new Highmark system has two components: real-time provider estimation and real-time claims processing.

"Real-Time Provider Estimation allows the provider to submit requests for specific health care services -- before a member receives care or at the time of service ��" and estimate the member's financial responsibility within seconds," Highmark explains. "Real-Time Claims Processing gives providers the added ability to submit claims for specific health care services and receive a fully processed claim response within seconds."

You-ll be able to use these cost-estimate tools prior to service or at the time of service, and then you can either immediately collect payment or make payment arrangements with the patient.

The benefit: "This will allow providers to let the patients know exactly what the insurance will or will not pay so that they can determine whether or not they want to go ahead with the procedure," explains Dianna MacDonald, practice manager for George L. Rosenberg, MD, PC, in Natrona Heights, Pa.

Bonus: "If we can collect what is due on the day the procedure is performed, it will make my life much easier because I won't have to bill the patient and wait for the payment to come in," MacDonald says. "If the patient cannot pay in full, it would allow us to set up payment arrangements immediately."

Revamp your process: If your practice has access to a real-time claim estimation or claims processing system like this one from Highmark, consider updating your collections process to ensure you-re making the most of the information you can get from the payer. "With the increasing share of costs being shifted to the patients, it is imperative that practices put collections policies in place and proactively follow them," Martin says.

Tip: Using this new Highmark tool and similar tools may be more successful for your practice if you involve front-end collections staff. "I don't necessarily agree that this should be primarily a biller's job," Martin says. "I feel this would be more successful if the people on the front end who encounter the patient at points of collection and procedure scheduling are educated and proactively utilizing this tool."

Why: Pre-service cost analysis tools only help your collections efforts if you use them before your physicians provide the service. "Once the biller is seeing a balance due, many times the service has already been performed, and this tool would be a moot point," Martin adds. "I feel billing should really be a front office mentality to be the most expeditious, prosperous, and successful."

Highmark is the first insurer in the Pennsylvania region to roll out real-time capabilities, according to a press release from the payer. However, other payers are also beginning to offer real-time claims processing and more will likely develop real-time systems in the near future.

UnitedHealthcare, Humana, Tricare, and Blue Cross Blue Shield of South Carolina are just a few of the payers that offer real-time claims adjudication (RTCA) to their physician clients. RTCA allows you to view, at the time of service, how much insurance will pay and how much a patient will owe. (For more about RTCA, see the article "Boost Efficiency and Speed Up Reimbursement With RTCA" in Medical Office Billing & Collections Alert Vol. 8, No. 4.)

"I agree that this will be available by more and more payers. Similar tools have already been available," Martin says.