Addressing the Market: Determining Accuracy in Treatment Estimate Solutions 

Inflated patient healthcare costs are driving the adoption of treatment estimation solutions to mitigate financial concerns. While patients are concerned about treatment costs, healthcare providers share their distresses but from a different perspective.

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 outcome, errors are inevitable.

Many treatment estimation tools are designed to streamline claims submission and offer price transparency; however they often fall short in the following areas:

1. Dependency on historical data and generalized averages without real-time eligibility, insurance carve outs, and dynamic pricing structures.
2. Exclusively designed for claim submissions, many tools lack functions such as the ability to make a payment or provide a payment plan, missing the opportunity to enhance patient access and treatment acceptance.

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.

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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