How can physicians accurately calculate patient out of pocket expenses?

According to a study conducted in November 2021, the study surveyed 371 PCPs whether they are able to determine patient out of pocket expenses accurately. These primary care physicians (PCPs) were asked to estimate the out of pocket expenses every quarter of the year using the general cost sharing methods used by insurance companies such as out of pocket maximums deductible, coinsurance and copays.

They study revealed only 21 percent of the surveyed PCPs were able to accurately calculate the out of pocket expenses even after the insurance companies provide both physicians and patients of the plans and prices.

Out of pocket expenses have risen significantly in the US because of a mix of medical services costs and insurance cost-sharing. Hence, 33% of patients experience difficulty spending doctor’s visit expenses (copay), even the insurance companies cover 80% of the actual cost for the medical care services performed.

The survey states that patients who battle to manage the cost of hospital expenses might want to reduce their medicine/pills by half or take their medicine/pills rarely.

CDC reported, roughly a ⅓ of Americans postpone medical services access due to high out of pocket costs, on contrary to the survey’s outcomes and numbers, most doctors taking an interest in the exploring to accept it is important to have commitment to their patients and provide useful observations in regards to the expense of care with their patients. Doctors giving exact costs can allow patients to know the level of care provided and get educated to make choices with regards to their overall health and finicalical wellbeing.

Doctors should provide the prices and be transparent if the medical care services are ongoing for the patient. So that they will be aware of cost and make necessary arrangements with the insurance companies to pay non-covered services.

CMS issues price transparency protocols to doctors that US medical clinics/hospitals give transparent data about care plans and services. In any case, a consistency report assessed 94% of studied medical clinics were seen as rebellious with guidelines a half year after CMS carried out it.

The transparency rule is expected in emergency clinics to show data on their site with respect to overall charges, payer related arranged charges, limited out of pocket costs, and identified least and greatest arranged prices. The level of care was planned to permit patients to get a clear picture to evaluate data and make them aware of the expense of their medical services therapy or prescription before proceeding.

As non-compliance proceeds, CMS will charge a penalty for emergency clinics under the 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule. Emergency clinics who do not follow these protocols provided by CMS, with north of 30 beds will be fined a punishment of $10 per bed. This new guideline can require non-compliance medical clinics to be liable for paying a limit of $2 million.

However, given all the guidelines by CMS and other insurance companies, physicians have a hard time going through all the guidelines line by line or payer by payer. BillingParadise’s Eligibility and benefits verification automation system can provide detailed eligibility and benefit information, which can be provided to the patient during the time for service, so that they will be aware of their out of pocket expenses and covered benefits.

The question may arise how hospitals and clinics can obtain particular benefits according to specialty. For instance if the clinic is an ER or ASC and they have already provided the patient the services and wondering if the patient’s plan has ER/ASC coverages, whether they have any limitations in the plan, all the front office needs to do is log in to our eligibility and benefits verification automation system and key in the patient name, DOB, insurance member ID and select the speciality as ER/ASC and only these benefits will be visible.

Third party applications like Availity will provide you the basic information on the patient plan, but fail to deliver the specific information required for that particular speciality and services which the clinic or hospital wants to know. BillingParadise’s Eligibility and benefits verification automation system can provide the clinic/hospital staff exactly what they are searching for. We all know that saying the benefits to the patient will eventually let them forget, which is why  BillingParadise’s Eligibility and benefits verification automation system provides a PDF copy of the specific benefits through email or to their phone number which is mentioned in the EHR which enables patients to go back and check the benefits and make necessary arrangements like payment plans, if they do not have benefits for that particular speciality or services.

Regardless if the hospital or group practice receives hundreds of patients visiting per day, BillingParadise’s Eligibility and benefits verification automation system can run bulk eligibility reports. Front office staff just have to upload the patient appointment report from the EHR system, within 10 mins you will be able to obtain complete benefit and eligibility information in a spreadsheet which is downloadable and kept in clinical records so that physicians and clinical staff can go back and review the benefits in the past.This will not only allow to streamline their patient population, but also able to educate patients on the out of pocket expenses and how they can device a accurate care plan which will benefit both patient and provider respectively.  

Going back to outstanding patient balances, keeping records of previously checked eligibility data will be very useful for patient services staff in the hospital and clinical group when they are sending statements to the patient. Along with the patient statement, billing and patient services staff can actually attach the previous records of eligibility for the patient to identify the actual out of pocket expenses they need to pay up front during the time for visit such as copay.

Other out of pocket expenses such as deductibles must be notified to the patient every calendar year for them to recognize how much family and individual deductibles they have, which will make patients aware of the current out of pocket expenses rather than insurance premiums existing in their plan.

Speaking of non-covered services; they do not come under traditional out of pocket expenses like copay or deductibles. Non-covered services are purely dependent upon the network of providers, plan categories and benefit limitations. Routine services are sometimes denied as non covered services because they have benefit limitations. Say for example I have a basic BCBS plan and this BCBS plan only covers according to the patient history and treatment trends of the individual or family, uncertainty is the more accurate term to describe for these kinds of non covered services.

Using BillingParadise’s Eligibility and benefits verification automation system hospital and clinical group staff can automatically obtain the non covered services of your particular speciality so that doctors and clinical staff can keep patients appraised on the covered and non covered services which will eventually assist them to change the plan or the benefits covered in their plan.

BillingParadise’s Eligibility and benefits verification automation system is a stand alone system which has capabilities of importing and exporting large volumes of eligibility and benefits checks.