As payment lags and appeals processes shift in the era of insurers' high denial rates, the impact on patient experience shouldn't be forgotten, notes Bob Boos, Vice President of Revenue Cycle at Centra Health.
How are insurers' rising denial rates affecting your approach with patients?
Bob Boos: "For a long time––20, 30 years––there have been constant metrics you're held accountable for. When you go meet with the board of directors or your CFO or financial leadership, you're often talking about the standard metrics: cash collections, discharge not final bill, A/R aging. What has become a newer metric is the patient experience: How is the patient going through the registration process, getting their bill, getting access to charity, financial discounts, and payment arrangements, how quickly they're able to take care of their bill, etc.
“How the increasing denials rate and payer delays have really impacted this is that you're getting patients who are getting bills four months, six months, or eight months down the road from the time of service, and the health system did not do anything inappropriate or improper to cause this. For example, let's say a patient is seen in January for an emergency department service, and the health system bills out the claim a couple of days later, the insurance company pays it 20 days later, and we send it out based on guidelines of a Level Four visit. The payer comes back and says, 'Well, we believe it's a Level Three visit, so we're only going to pay the Level Three reimbursement.' That puts this amount into a dispute. The difference between the Level Three payment and the Level Four payment becomes an insurance denial and becomes a dispute over level. The health system needs to decide, 'Are we going to fight this balance, are we going to write it off and move on to the patient balance, or are we going to look for our reimbursement?'
“In these days of getting the most of our revenue cycle and fighting increasing costs, we're going after the additional revenue, because we truly believe we are following guidelines for coding, that we have billed this appropriately, that we are due the Level Four payment. What happens in this interim is we create an appeal, send records, and then send it back to a payer, who often takes four to six months to reprocess it, and the patient does not get their bill. Many EHRs do not allow you to bill this interim amount until the insurance company is finalized, until the adjudication is finalized.
“In this four to six months interim, let's say the payer comes back and pays the appropriate amount. Great! If they deny it again, however, we must again make another decision, 'Are we going to continue to fight it, or are we going to adjust it off and bill the patient for their balance?' Either way, once this happens, we change this balance over to the patient, and we release this statement. Now, to a patient that does not know, they're now getting a bill in October for a service they received in January, and it looks to them like, 'Oh, the health system, boy, they got their billing screwed up. They're not doing their billing right.'
“When, in reality, the health system has done things correctly the whole time. We are fighting to get our proper reimbursement and not billing a patient until we get a final number, an accurate number that we're billing them. This lengthy process eats away at the patient experience, and that's something that we have to combat. So, what we (at my organization) is when we get patient surveys, if they take a moment to say, 'You know, we got a delayed or late bill,' then we're going to call them, email them, or send them a letter and explain that we did not hold this bill. 'We are not late getting you this bill. This is what happened: Your payer did not pay the proper amount. We had to resubmit the claim and fight to get it paid. It took four to six months.' And then, generally, a magical thing happens that when you take the time to explain it to a patient, they are then able to have the ability to call their payer and say, 'Why are you doing this? Why are you having these issues?' So that's more of a targeted response. So we're able to get away from it being the health system has the problem, or the health system is not able to do the right thing, and show the actual blame where it belongs.”
