Reduce Uncompensated Care by Automating Accurate Cost Estimates

In the previous blog entry in this series, we looked at how A/R processing time can be reduced through Intelligent Automation, with a focus on timely and automated payer status checks.

But can automation also be used to reduce the number of accounts that go uncompensated? And how can it help with adherence to new CMS regulations that require transparency in showing payer-negotiated prices and real-time cost-sharing information? In this post, we dive into these topics, while also focusing on how a solution that lowers uncompensated claims numbers while adhering to CMS regulations can also have a significant patient experience benefit.

Are Patients Shopping for Services at Other Providers?

It’s well known to many revenue cycle leaders that presenting patients with an accurate price estimate for an upcoming service can help eliminate surprise out-of-pocket expenses. In turn, this allows the patient to prepare financially for upcoming bills, which increases the likelihood of on-time payment and decreases the amount of uncompensated care that is written off by the provider. With as much as 30% of hospital revenue coming from patient’s out-of-pocket expenses, it’s now more important than ever to maximize the chances of realizing that revenue. Patient experience is also positively impacted, as there is less chance for surprise at costs presented post-procedure, which increases the likelihood of the patient continuing to use a provider’s services.

Patient consumerization, with patients taking a more active role in their personal health, is also driving the need to provide cost estimates. More and more, patients are forgoing care because of high costs, or seeking home remedies instead of professional medical attention. Recent studies have shown that 70% of Americans struggling with medical debt have insurance, but still have a hard time meeting out-of-pocket healthcare costs. When a procedure isn’t avoidable, patients actively “shop” providers to understand what the costs will be, and identify where they may get the best deal. By not providing up-front cost estimates, or making them inconvenient to obtain, patients are more likely to have services performed by a provider whose costs are known and presented in a straightforward manner.

New CMS Regulations Place Additional Burden on Staff

Besides the benefits of patient experience and reduction of uncompensated care mentioned above, new CMS rules that go into effect in 2021 will require providers, as well as payers, to make certain pricing information clearly available to consumers. This includes hospital standard charges and payer negotiated rates for all services offered, as well as an easily consumed and searchable list of “shoppable” services that are more frequently accessed. The burden of this activity is increased in situations where health systems have different negotiated rates from facility to facility, or even physician to physician.

Providing a real-time price estimate in a self-service manner is difficult to achieve, with factors such as understanding the specifics of a patient’s coverage and changes to negotiated reimbursements with multiple payers occurring at different intervals and varying across facilities or physicians. Because of this, many providers still require patients to establish contact by phone, and via conversation the price estimate is calculated manually by their team. The inconvenience of accessing information this way may lead consumers to choose facilities that provide easily accessible transparent pricing. Also, with the new CMS price transparency rules in place, providers without automated methods to obtain, conglomerate, massage, and make available this pricing information on an ongoing basis will have an additional set of tasks placed on already stretched teams.

Automate Price Transparency to Delight Patients and Free Up Staff

Robotic Process Automation (RPA) allows software robots to be created that mimic the activity of human staff performing a repetitive business process. The software robots interact with electronic systems in the same way that humans do. They can interact with desktop, thin client, and web-based applications; read and send email; extract information from text or handwritten documents; and much more. This means that existing electronic systems don’t have to change to automate processes with RPA, and that complex programmatic systems integration can oftentimes be avoided OR orchestrated more easily through RPA itself.

RPA can be used as the engine to drive real-time and accurate price estimates for patients through self-service. Instead of having patients make a phone call, a health system’s website can allow patients to provide details of an upcoming procedure. Using the information provided, RPA software robots perform queries against internal provider chargemaster data as well as in real time against payer systems directly. RPA can then conglomerate the costs obtained, including breaking down estimated insurance coverage and out-of-pocket expenses to provide a patient with an accurate estimate within moments right on the website. The logic built into the automation can also be used to show additional incentives associated with the procedure being estimated, such as prompt-pay or self-pay discounts.

Price estimation automation doesn’t have to stop with website form-based inquiry. The same RPA logic that is used to provide cost estimates through the web can also be used to drive innovative chatbots, or an automated phone interactive voice response (IVR)-based capability for patients not comfortable or capable of using the web.

Extending the scenario from above, if contact details, such as email, are also collected when patients ask for price estimates, RPA can automatically send follow-up emails to the patient with richer information to break down the service request, or provide patient education materials. RPA can also notify hospital staff of the price inquiry, which allows for proactive contact as the provider now realizes the patient is shopping for services.

With RPA in place, CMS rule compliance becomes easily achievable without placing additional workload on existing teams. While RPA won’t be used to display the required data to patients (this will likely be done through a provider’s website), RPA can be used to ensure that the data being displayed is always up to date and accurate. It can pull internal chargemaster data, as well as payer data like negotiated rates, and format this data exactly as needed to be used in the provider’s web presence. The automation can run as frequently as needed to ensure the information is always up to date, with minimal staff involvement needed in the ongoing process. Many providers will of course want to be able to check new datasets before they’re made publicly available. Through the automated process, notifications can be sent that updated charge data is ready for review. This can be done through existing ticketing systems, like ServiceNow, or through native RPA platform capabilities like UiPath’s Action Center. Once a provider’s staff has approved the price transparency data that RPA has updated, the automated workflow takes back over to move that new information into place so that it is usable on the provider’s website. 


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