Industry Voices—Why EMS need to adapt billing for high-deductible health plans

Patient confusion about insurance coverage can often translate into delayed billing and increased cost of collections. (katifcam/GettyImages)

Patient confusion about insurance coverage can often translate into delayed billing and increased cost of collections.

With now more than 40% of privately insured Americans enrolled in a high-deductible health plan, according to a recent survey published in JAMA Internal Medicine, the risk of unpaid bills is steadily increasing. While most emergency medical services (EMS) agencies are actively tracking the negative impact of these trends on their cash flows, few are focusing on the ancillary costs associated with high-deductible plans, including higher operational costs and higher cost of collections due to poor patient engagement.

By augmenting their billing and collections operations with technology-enabled solutions, both at dispatch and post-transport, EMS agencies will be better equipped to submit cleaner, more complete claims, increase billing transparency and, as a result, improve profitability. 

Incomplete patient data and lack of billing transparency are adding fuel to the fire

At dispatch, validating patient information, including insurance coverage, payer requirements, deductibles and copays, is often difficult, especially in emergency situations when treating the patient takes center stage. Most agencies understand that limited or inaccurate patient details and insurance information can lead to significant billing challenges down the road for agencies.

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What they often overlook is that, because emergency ambulance transports are assumed to be covered by most major insurance plans, patients often do not understand their patient responsibility, including copays and deductibles, which amplifies the problem.

Patients with high-deductible plans—when high balances remain—are often surprised to discover they are responsible for the full charge of their ambulance trip, causing confusion and frustration. Adding to the confusion, while federal law requires that insurers bill consumers for emergency-room services as if they were in-network, this does not cover everything, such as the ambulance ride getting you there, as The Palm Beach Post reported.

Additionally, most patients do not realize that many emergency transportation companies have made the business decision not to contract with insurance companies because they cannot agree on pricing terms, which means they are out-of-network, leaving patients to manage unnegotiated, seemingly exorbitant charges on their own, the Post reported.

Under these circumstances, it should be no surprise that one of the most common reason codes for billing call centers is related to patient confusion about having a balance when they have insurance. While a nuisance to patients, these calls are costly. Identifying opportunities to proactively address patient billing hurdles and improve the patient billing experience is paramount to improving not just the top line but the bottom line of EMS agencies’ budgets.  

Accelerate payments by enriching data at dispatch

Especially in the case of high-deductible health plans, verifying patient financial responsibility upfront empowers the dispatcher to proactively address billing issues that may be difficult to mitigate later in the revenue cycle. Leading EMS agencies are beginning to leverage application programming interfaces to establish direct connections into a broad array of data sources to enrich patient data.

By compiling a holistic clinical, financial and administrative profile for each patient at the time of dispatch, teams will be better equipped to flag missing information, validate patient identification, confirm insurance coverage and address payer requirements.

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By incorporating patient scoring and segmentation services, the dispatcher can also determine a patient’s (or responsible party’s) ability to pay, which is crucial in determining if payment upfront is appropriate, such as in the case of non-emergent medical transport, and provides insight to the billing staff regarding the need to offer financial services and payment options.

These actionable insights can also be leveraged post-transport, ensuring claims are complete prior to submission or triggering workflows to address missing details. For non-emergent transports, pushing this information to the paramedic via the electronic patient care record also facilitates more informed patient engagement.

Reduce the cost of collections by optimizing the patient experience  

Post-transport, patients are often left managing multiple bills and deciphering confusing explanation of benefits (EOBs), resulting in delayed or unpaid bills and adding to the millions of dollars unpaid emergency transport bills are costing counties each year. To proactively address these barriers and improve billing transparency, agencies can leverage a combination of low-tech and high-tech approaches.

At the end of a transport, when patient medical records are provided to either the patient or patient’s caregiver, paramedics can take this opportunity to provide information about the agency’s patient web portal.

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Additionally, if during the billing cycle staff uncovers missing insurance information, they could proactively reach out to the patient prior to submitting a claim, avoiding an uncomfortable and confrontational call had they waited until the bill was with collections. This approach fosters trust, provides the patient an opportunity to address documentation gaps and reduces risk of claim denials.

To improve patient engagement long-term while addressing concerns about billing transparency, many agencies are taking steps to redesign their patient portals to optimize the overall patient experience, not just collect payments. Unlike legacy patient portals that were glitchy, difficult to navigate and provided little, if any, recourse for correcting outdated or incorrect patient information, these modern systems are leveraging user interface and user experience best practices that focus on ease of use and leverage scientifically proven techniques to create a more intuitive and productive user experience while mitigating risk of human errors.

Additionally, these portals are designed to ensure patients have a complete picture of their overall bill and patient responsibility, including the option to drill-down to specific EOB details. Lastly, they enable key features like profile management, insurance updates and electronic signature capture.

Concluding thoughts

Revenue leakage risks span the billing and collections cycle, and the advent of high-deductible plans have exacerbated them.

Due to the confines of legacy billing operations, the majority of EMS agencies focus first on cleaning claims prior to submission and actively monitoring accounts receivable and denial trends. While these operational aspects are also key to revenue cycle success, taking a proactive, technology-enabled approach to enrich patient data at dispatch and promote a transparent, simple billing experience for patients can further mitigate these leakage risks and help agencies avoid them altogether.

Eric Foust is president of Integra Connect Revenue Cycle Solutions, EMS Division. He has served in several executive positions and has more than 20 years of experience in the healthcare industry.