Consumer Directed Health Care: An Update for Providers
Consumer directed health care (CDH) is a fast-growing trend. But is it creating more hassles for providers (and fewer positive health outcomes) than expected?
“Patients are being encouraged to act more like consumers of health care,” said Melissa Lukowski, athenahealth’s Director of Payer Outreach. “They can now compare various options for health coverage, including traditional health care plans, high-deductible plans, and other products such as personal health care spending accounts.”
The idea behind consumer directed health care is to equip consumers with information so they can choose the most appropriate coverage, thereby reducing the amount of unnecessary care they receive and seeking lower-cost, higher quality providers. According to a recent RAND report, however, “Critics wonder if such incentives (or disincentives) may lead patients to skimp on care that could drive up costs in the long run.”
CDH presents a significant challenge to practices as well: high deductible plans shift a sizeable financial burden onto providers who must collect higher payments from patients. In fact, it’s difficult for providers to know which patients have high deductible plans before submitting a claim to their insurer. So these patients – like others – walk out the door after receiving services. And the practice must bill and collect on much higher amounts.
This means more staff time to follow up on billing, and more unpaid claims.
Payers to the rescue?
Payers have developed an array of tools to help providers collect on high deductible plans. But there are several barriers to their implementation. First, they require the provider to log onto different payer website portals in order to use tools for each payer. Imagine having to go to a handful – or even dozens – of different payer websites in order to figure out what each patient owes for a visit, and having that information ready for all the patients at check out. The added complexity is not attractive to already busy practices.
Another barrier is that patients simply aren’t used to paying large amounts at the time of service. Many prefer to see a printed explanation of benefits (EOB) in the mail before sending payment. So practices not only face changes in workflow to collect at the time of service, but they are taking responsibility for educating patients during the transition (and risking dealing with unhappy clients at check-out).
Real-time adjudication: athenahealth’s solution
athenahealth decided to find a way to help its practices recover from these increasing financial burdens. So in 2007 we launched the first fully-integrated all-payer platform enabling our entire client base to perform real time adjudication (RTA) of medical claims at the point-of-service for participating payers.
For athenahealth clients, RTA solves the technical challenges of understanding what the patient owes at the time of service. That’s because RTA means using a single portal – athenaNet® – to submit an electronic claim through a payer’s adjudication system. The practice gets an adjucation response, including adjudication details, within seconds. Receiving the claim adjudication response in real time means that the practice knows the patient responsibility portion of any given claim almost instantly. Ideally the patient portion is at check out.
But how does RTA work with patients?
athenahealth clients report that after an initial adjustment period, patients acclimate to paying balances at check out. The key to success is providing patients with education about the new process, including printing out the payer’s RTA responses and reviewing everything with each patient. This means that front desk staff needs to be prepared with handouts and answers to commonly asked questions.
In one example, a practice in Ohio began using RTA as soon as athenahealth made it available. “We thought there would be some complaints from patients at first, but it went much better than expected,” said Brenda Dunham, Billing Manager at Englender, Sper & Drasnin MDs Inc. located in Milford, OH. “For the first month, there were a few people who didn’t understand the process. Some said they preferred to see their printed explanation of benefits in the mail before paying anything.”
But after initial patient education and some time to adjust to the process, the practice found that people were generally open and willing to pay their full balances at checkout.
“Using RTA is fantastic. We’re so glad we’ve started it,” said Dunham. “There are some claims that we can’t send through RTA, but it has definitely improved our workflow - and cash flow - since we’re not waiting and following up on a lot of self-pay balances anymore.”
More challenges ahead
athenahealth’s RTA solution helps practices experience improved financial results while making minimal changes to workflow. But at this time, only two major payers (Humana Inc. and United Healthcare) fully participate in RTA. For claims that go to other payers, there is still inconsistency in how RTA works.
Some major payers rely on the eligibility transaction to estimate what the patient will owe at check out. And others, wary of betting on new technology, have adopted a “wait and see” approach.
But athenahealth – always on top of emerging trends that help practices stay profitable and maintain good patient care – is forging ahead. “Real time adjudication is something that providers have been wanting for decades,” said athenahealth’s Lukowski. “We’ve seen RTA successes with our clients, and because we know consumer directed health care is here to stay, we are committed to making it work.”