Despite staffing shortages, medical groups strive to provide a superb, personalized patient experience in an increasingly price-sensitive environment. Growing numbers of uninsured, under-insured, and high-deductible patients continue to challenge financial performance. Fortunately, there are ways to improve the patient’s financial experience while also improving self-pay collection.
Namely, implementing presumptive charitable screening — to determine eligibility for free or discounted medical care under the provider’s financial assistance policy — at the front end of the patient encounter is a reliable way to improve patient engagement and ensure that accurate, compliant pricing is provided. Furthermore, engaging patients financially at the front end drives higher reimbursement with less effort and lower administrative costs.
Increased regulatory pressure for medical groups
Medical groups and the healthcare industry at large have faced heightened pressure to provide financial support and information to patients in 2022.
Implemented on Jan. 1, 2022, the No Surprises Act is designed to protect patients from unexpected bills and offers protection from out-of-network charges. Medical groups must provide uninsured or self-pay patients with a good faith estimate (GFE) of their discounted cash price. To do so, they must first determine whether the patient is even eligible for a GFE, which means requesting W-2s and manually chasing down current insurance status within a strictly defined timeframe. The Act has significantly increased the level of administrative burden (even if only for a small percentage of patients) for many providers.
Given the circumstances, the stakes for improving collection rates without adding to the administrative workload have never been higher.
Presumptive charitable screening: The key to higher reimbursement
In their search for effective ways to improve financial performance, medical groups have uncovered a surprisingly simple truth: Using real-time, presumptive charitable screening technology at the beginning of a patient encounter reduces the administrative burden of manual screening, ensures Office of Inspector General (OIG) compliance, and improves self-pay collection rates.
“When a patient knows in advance what will be covered by their insurance and what won’t, they’re empowered to make informed decisions,” says Juli Smith, Director at ZOLL Data Systems. “If there is a hardship, medical groups with charitable discount programs can offer a payment plan prior to providing service, reducing the risk that the patient will defer medical care for financial reasons.
“If there is no hardship, but the patient is self-pay, you may want to offer a prompt-pay discount,” adds Smith. “Partnering with the patient on the financial responsibility early in the process increases the odds of collecting maximum self-pay dollars.”
Before offering financial hardship or prompt-pay discounts, medical groups must have a plan in place to ensure compliance. Failure to do so risks running afoul of the False Claims Act1 and OIG advisory opinions related to the Federal Anti-kickback statute.2 Fortunately, knowing the law and establishing (and publishing) a policy and procedure that treats all patients equally will address compliance issues and protect medical groups from lawsuits or criminal charges.
The return on investment for financial screening
There is a strong business rationale to support presumptive charitable screening. “Industry research shows that more than 91% of medical expenses from uninsured patients and 56% of patients with out-of-pocket medical expenses never get paid,” says Smith. “Offering competitive, patient-centric financial care improves the odds of receiving optimum reimbursement.”
If financial assistance is targeted precisely to patients’ circumstances, they are more likely to pay in full, and their payment levels will help providers achieve the highest possible revenue.
Yet, the staffing realities of most medical groups can make it difficult to implement a new program, particularly while dealing with the administrative challenges of new price transparency laws. That is where automated accounts receivable (AR) optimization and patient eligibility tools come in. Automated presumptive charitable screening tools reduce the burden of manual screening and help ensure compliant discounting and accurate GFEs. Best-in-class technology streamlines workflows and returns accurate, reliable data in near-real time.
Forward-thinking medical groups are using this information at the beginning of the encounter to provide price transparency, to identify and enroll eligible patients in Medicaid, and to presumptively qualify them for financial assistance. High-quality demographic and eligibility data enables them to gain insight quickly and cost-effectively and to make informed decisions about hardship discounts, customized payment plans, and more. Taking this proactive approach removes access barriers and ties price transparency to what people can realistically afford.
Three steps to improve self-pay collection
Complying with price transparency rules and offering customized patient financial care in line with industry and government regulations involves three steps:
- Step 1: Develop and publish a clear, understandable patient discount and financial assistance policy, and apply it consistently to all patients.
- Step 2: Get best-in-class, presumptive charitable screening technology to find more data that is OIG-compliant — faster and without adding to staff workload. Tools for demographic enhancement, insurance verification and discovery, deductible management, and self-pay analysis quickly and accurately determine the patient’s financial situation, eligibility for charitable assistance or retroactive Medicaid, propensity to pay, and more.
- Step 3: Use the financial profile to develop a compliant, patient-centric package, including one or more of the following:
- Transparent pricing based on the patient’s financial situation
- A financial hardship discount (per your published policy)
- Government assistance (retroactive Medicaid)
- A prompt-pay discount
- A payment plan customized to the patient’s financial situation.
Early patient engagement supports healthy financial performance
Presumptive charitable screening tools, such as those in the ZOLL AR Boost solution suite, are an important enabler for meeting your medical group’s price transparency and charitable discounting objectives. Treating the patient as an individual, both medically and financially, can have transformational effects. The patient receives the care they need, free from uncertainty related to their financial obligation. At the same time, medical groups take greater control of their revenue cycle, optimizing reimbursement, and reducing the administrative burden placed on their staff.
- “The False Claims Act.” The United States Department of Justice website. Available from: https://www.justice.gov/civil/false-claims-act. Accessed 1 November 2022.
- “MGMA submits comments to CMS to improve the uninsured and self-pay GFE requirements.” MGMA. Available from: https://www.mgma.com/advocacy-letters/march-7-2022-mgma-submits-comments-to-cms-to-improve-the-uninsured-and-self-pay-gfe-requirements-2. Accessed 2 November 2022.