Addressing the Market: Determining Accuracy in Treatment Estimate Solutions 

The cost of healthcare is one of the most common barriers to treatment acceptance and adherence.  Recent studies show that the lack of transparency creates friction across the entire care continuum from the first sign of symptoms through treatment adherence.

Patients unable to estimate out-of-pocket costs in advance, delay or forgo treatment due to budget concerns. Continue reading to understand the most common factors driving price transparency demand.

Driving Factors | Price Transparency Solutions

Five main factors driving the adoption of price transparency solutions to mitigate patient financial concerns throughout the patient journey:

          1) Retail Experience | Patients expectations for retail-like experiences when receiving healthcare services are on the rise due to accessibility and convenience of modern technology in all other facets of life.

          2) High-deductible Health Plans | The rise of high-deductible, high-premium health plans increased patient responsibility and caused patients to become more invested in understanding cost of treatment.

          3) No Surprises Act | The No Surprises Act, which went into effect January 1, 2022 required hospitals and emergency care providers to provide out-of-pocket cost estimates for out of network providers and uninsured patients.

          4) Pandemic-era Policies Ending | Public health emergency provisions and waivers ensuring care during the pandemic have ended, causing patients to experience loss of coverage and higher costs.

          5) Inflation | The inability to afford medical test and treatment has caused the highest rate of patient’s delaying care in more than 20 years.

While patients are concerned about treatment costs, healthcare providers share their distresses due to long-term and short-term effects this has on patients and practices alike.

For healthcare practices, inaccurate cost analysis can inflate billing discrepancies, disputes, and delayed payments causing strain on financial operations and diverting crucial resources away from patient care. Providers familiar with the complexities of medical billing and access barriers fear inaccuracies due to the following variables:

• Changes in patient eligibility
• Prior authorization outcomes
• Coding by payor contract rates and modifications
• Unforeseen treatment complications
• Discontinuity of care

Without a configurable solution designed to factor in all the variables that may affect the estimate outcome, these solutions can cause uncertainty for the patient requiring additional resources dedicated to patient education and potential negative impacts on financial performance.

Market Challenges | Price Transparency Solutions

Numerous treatment estimation tools were developed to support the no surprises act and to streamline claims submission. However, their accuracy can vary for the following reasons:

          1) Patient Eligibility | Accurate price transparency requires a real-time benefit investigation to ensure the most up-to-date information is obtained. They should also consider all out-of-pocket expenses such as; deductible, coinsurance, copay amounts and coverage by procedure code.

          2) Singular Procedure Rates | Self-service patient treatment estimate solutions typically generate estimates based on a single service the patient selects from a list of common diagnosis and procedures.

          3) Contracted Payor Rates | Treatment estimates based on historical claim data and out-of-pocket averages across your patient population increases the margin for error.

Advanced technology configurable at the provider-level enables practices to apply custom rules including carve outs, modifiers, rates and dynamic pricing structures for ongoing treatment plans. Treatment estimate solutions that leverage real-time eligibility data in each transaction ensures the patient information is accurate and up-to-date with recent changes to coinsurance, deductibles and coverage options.

Market Need | Price Transparency Tools

• Configurable, provider-level treatment estimates, enable practices to deliver the most accurate price transparency experience.
• Treatment estimate solutions that leverage real-time eligibility data in each transaction, ensure patient coinsurance, deductible and coverage information is accurate and up-to-date.
• Advanced technology incorporates contracted rates by payor and custom business rules to include practice-level modifiers and dynamic pricing structures. Integrating treatment estimates into your patient access strategy, streamlines revenue and increases treatment acceptance rates.
• Offering patients a convenient way to apply a copay payment, pre-authorize a post-adjudicated payment amount, or set-up a payment plan based on the estimate.

Assessing Treatment Estimate Vendors: Questions to ask

When considering working with a vendor, it’s essential to ask a series of questions to evaluate the vendor’s capabilities and suitability. Here’s a list of questions to consider:

Ease-of-Use:

• What information is required to generate an estimate?
• Can I create an estimate based on the appointment or does it require a claim to be generated?
• Can I group frequent service offerings in a template to avoid excessive data entry?
• Where is the estimate stored for later reference?
• What kind of training and support do you offer to healthcare providers and their staff to ensure smooth implementation?
• Is your platform compatible with our existing electronic health record (EHR) system, or will it require custom integration?

Accuracy:

• Do your estimates leverage our current contracted rates or historical claim data?
• Is a new eligibility transaction run each time or does it leverage the existing information on file?
• Can I apply provider-level modifiers based on education and fee schedules?
• Can I apply pricing structures such as discounts or fees based on the services applied?
• Can I apply carve-outs and payor-specific rules to CPT codes?

Patient Experience:

• What methods can I use to deliver the estimate to the patient?
• Is the estimate easy to understand and define the various costs?
• Does the estimate explain good faith estimate regulations and provide instructions on how to appeal?

Practice Operations:

• How can your solution streamline our billing and revenue cycle management processes?
• Can your solution be customized to meet the specific needs and workflows of our healthcare practice?
• Are there additional costs associated with customization or scaling up the service?
• What level of customer support is available, and how can we reach your support team in case of issues or questions?

By asking these questions, healthcare providers can gain a better understanding of a vendor’s treatment estimate solution and make an informed decision to ensure ease of use, accuracy, and practice efficiency.

Advantages to ClearGage Treatment Estimates:

Real-time Eligibility Data: ClearGage taps into live eligibility data to provide up-to-the-minute information on insurance coverage, co-pays, and deductibles, ensuring patients receive the most accurate cost estimates.

Custom Rules Engine: Our customizable rules engine allows healthcare practices to tailor cost estimates to their specific pricing structures, considering variables such as carve outs, fee schedules and provider level modifiers. ClearGage configures each practice with custom business rules at implementation so users can set it and forget it, making estimate generation seamless and timely.

Financial Management: ClearGage’s unique approach enables providers to initiate payment plans, collect patient copays or payments in full, prior to treatment – supporting patient and practice financial management.

Learn more about ClearGage treatment estimate solution by scheduling a demo with a ClearGage solutions expert today!

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