While a glance at a recent paper medical bill might make that goal seem downright futuristic, a few coalescing forces just might make transparent transactions commonplace. Under the ACA, state and federal insurance exchanges, which opened Jan. 1, will accelerate the trend of Americans assuming greater financial obligations for their medical bills.
That makes health providers more vulnerable to losses, given the lower payment rates of consumers. The faster and easier hospitals and doctors can make the process of paying bills, the more money they'll collect.
High deductibles, high stakes
The stakes will only get higher each year. The continued migration of consumers to so-called high-deductible health plans is estimated to grow to include 54 million participants by 2017, up from 38 million in 2013, according to Aite Group, a consulting firm in Boston. These accounts comprise health savings accounts (HSAs), flexible spending accounts (FSAs) and health reimbursement accounts (HRAs).
Under the ACA, state and federal insurance exchanges, which opened Jan. 1, will accelerate the trend of Americans assuming greater financial obligations for their medical bills.
HSAs are a common feature in the exchanges and are increasingly being chosen by employees in private group plans. Many of these plans require patients to pay 100 percent of medical costs out of pocket up to a certain dollar amount annually – often $6,000 or more.
Meantime, insurers are raising deductibles on non-copay services in traditional preferred provider organization (PPO) plans. For people with high deductibles, breaking a leg or having an appendix removed in 2014 could easily result in an out-of-pocket expenditure of $6,000.
Providers reevaluate patient payments
"There will be more people with high-deductible plans in the market," says John Adractas, chief marketing officer of Simplee, a healthcare payments vendor based in Palo Alto, Calif. "That is going to represent more pressure on the patient payment side. You are going to have to work really hard for people to be able to understand their bill and make payment successful."
To that end, hospitals and doctors have taken notice, says Michael Trilli, a senior analyst at Aite. "They are starting to feel the impact," he notes. "You are seeing a little bit greater commitment to the patient payment side, on the technology, as well as the business process."
Big opportunity for processors
The need for better processing has created a market opportunity for the likes of Simplee, which helps health providers move payments online, speeding up the process and lowering costs. Other players include Wellero, owned by Portland-based holding company Cambia Health Solutions, and PatientPay, located in Durham, N.C. These services all aim to make collections easier for health providers by making it simpler for patients to pay bills online or via their mobile device.
For example, El Camino Hospital, based in Mountain View, Calif., turned to Simplee to improve collections. In a six-month period, Simplee's platform helped the hospital shift self-service to 33 percent of its online collections, up from 2 percent. Staff-assisted transactions declined 40 percent, and 80 percent of patients paid within one day of an email bill alert.
The coveted "Holy Grail" for streamlining the patient payments experience is the incorporation of insurance contract pricing and deductible amounts in real time. Initiating collection at the point of service greatly increases the odds of payment, research shows, and patients are more apt to pay if they understand their bills and trust their billers.
Last year, Wellero launched a mobile app for testing on a small scale that allows patients to pay at the time of service after the app calculates the patient's benefits and total price. The differentiator: The software allows the insurance payout to be adjudicated at the point of service. While Wellero is a new player, it has the advantage of working with its parent company, Cambia, to integrate key insurance information on its plans in Western states. The company has its sights on building volume in 2014.
The coveted "Holy Grail" for streamlining the patient payments experience is the incorporation of insurance contract pricing and deductible amounts in real time.
"As patients ourselves, we saw a need for the ability to check in, see the price of the service and calculate the cost of the visit based on our insurance coverage," says Hanny Freiwat, cofounder and president of Wellero. "We wanted to pay at the provider's office if we were incented with a prompt payment discount or just to avoid the confusing paper trail that precedes the actual bill."
"The deductible and out-of-pocket are the most critical pieces [of information], in addition to all the rules the health plan applies," Freiwat adds. "We apply it all at the time of service and generate the exact number."
Providing this transparency is the hard part, adds Mike Harris, a Minneapolis-based managing partner at Core Innovation Capital, a private equity firm focused on underbanked consumers. An accurate final bill reflects detailed insurance information, such as how much of a patient's deductible is left, whether the provider is in network and what other claims are outstanding, among others.
"This is a process that is very information-intensive," says Harris, who has worked for a health insurance company. "As the speed of information and the ability to bring information to consumers' fingertips get better, the faster we will be able to process those transactions."
Despite the challenges, we're likely to see increasing transparency in healthcare billing. Transactions that have price transparency — those showing clear itemization of services rendered — will grow to $3 billion by 2016, up from just $540 million in 2012, according to Aite.
"There is a move by the healthcare community to try and automate as much as possible," says Priscilla Holland, senior director of healthcare payments at NACHA, an industry organization that sets standards for ACH payments. "They are being pushed by the regulation to reduce their costs, and focus more time and money on the clinical side of their business."
Call it means to an end.