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Kelli Turner | December 18, 2019

Four Ways Billing Teams are Addressing the Rise of the Self-Pay Patient

(5 min read) “Self-pay” used to be a designation reserved for patients who are uninsured and covering the cost of medical expenses on their own. Over recent years, this patient moniker has evolved to encompass a new breed of self-pay patient. As health plan deductibles and out-of-pocket expense caps have ballooned, so too have the number of patients covering significant medical expenses on their own, prior to insurance kicking in.

A study conducted by Black Book Research revealed 30% growth in patient healthcare costs between 2015 and 2017. A federal survey published by the National Center for Health Statistics found that high deductible health plan (HDHP) enrollment surged in 2018 to include nearly half of the privately insured patient population. The survey defined HDHPs as private health plans with annual deductibles of at least $1,350 for individual coverage or $2,700 for family coverage. Unfortunately, a significant portion of the population—42%—could only afford $500 or less before facing financial issues, according to the Physicians Foundation 2019 Survey of American Patients.

Young couple calculating their domestic bills at home

Increased financial pressure on HDHP-insured patients coupled with an up-tick in the uninsured population is producing tighter financial margins for healthcare providers. Surprise medical billing adds further fuel to the fire. Among emergency room visits in 2017 by people with large employer coverage, an estimated 18% had at least one out-of-network charge. Surprise billing trends are expected to continue as payers continue to pursue narrow networks.

The Impact on Provider Reimbursement

The rising tide of self-pay patients, those who are uninsured and those coping with surprise medical bills has created a perfect storm for healthcare provider reimbursement. Healthcare analysis by TransUnion revealed that revenue attributable to patient financial responsibility increased by 88% from 2012 to 2017 in hospitals–a trend that undoubted holds across care settings. As patients struggle to pay, providers struggle to collect.

The biggest challenge for healthcare organizations is that it costs four times more to collect from a patient than it does to receive reimbursement from a payer. According to research published by the Journal of the American Medical Association on expenses associated with billing and insurance-related activities, professional billing costs were estimated to represent:

  • 14.5% for primary care visits
  • 8.0% for general medicine inpatient stays
  • 13.4% for ambulatory surgical procedures
  • 25.2% for emergency department visits

With the volume of self-pay accounts reaching unprecedented levels, healthcare organizations are having to reapproach traditional billing processes.

Black Book CEO Doug Brown aptly summed up the problem for many healthcare entities, observing that “health care providers spend significant resources and time to try to collect payment with outdated, often very manual, processes. Even with patient liability increasing five times faster than overall reimbursement, some health systems are not equipped to adapt to this trend.” Brown points to disparate data sources and the lack of internal analytics skills as obstacles holding many organizations back.

These challenges are driving increased adoption of revenue cycle management (RCM) solutions as healthcare organizations endeavor to optimize billing processes. Black Book recently asked 1,453 financial management survey participants to identify their top drivers for acquiring RCM analytics tools over the next year and half. Top responses reflect a desire for solutions to help billing teams:

  • Predict payer remittance dates to manage organizational cash flow
  • Flag potential denials before they occur 
  • Identify inefficiencies and breakdowns in RCM processing at early stages
  • Predict changes in payer-specific rules for claims adjudication
  • Support patient engagement goals by refining processes that directly impact patient payment

How Providers are Forging a New Financial Path Forward

Automating processes to establish greater financial confidence earlier in the billing cycle is paramount to getting ahead of financial pressures. For healthcare billing teams struggling to identify, hire, and retain the RCM talent needed to optimize workflows, outsourced partners pose great promise. External expertise and technology solutions are increasingly helping providers bring automation to time-consuming, manual processes.

Process Automation on the Mechanism of Metal Gears.

Here are four ways technology is helping healthcare billing teams improve revenue cycle processes and the patient financial experience:

1. Patient data validation

One contributor to claims denials and barrier to insurance verification and discovery (particularly in emergency medicine), is missing or incorrect patient data. Many medical billing teams are adopting tools that automate the patient data validation process to ensure that information is in-tact and accurate on this first pass, stemming the downstream risk of denial.

2. Insurance eligibility verification

Access to details on patient insurance coverage are vital in billing. Resources that empower billing teams to quickly and easily tap into patient insurance details on co-payments, deductible thresholds, and benefit coverage reduce the risk of billing errors and improve processing times. Automated solutions enable billers to identify eligibility exclusions early in the billing process.

3. Insurance discovery

According to research conducted by TransUnion and published by the Healthcare Financial Management Association, up to 5% of self-pay patient accounts that are written off as bad debt actually have billable insurance coverage. IT solutions that automate the search for patient coverage are helping organizations increase billable coverage discovery rates and boost revenue. These tools also help identify secondary insurance coverage, including Medicaid, which can help reduce patient financial burden.

4. Self-pay patient analysis

To reduce the number of patient accounts being turned over for third-party collections, billing teams are adopting tools that help assess a patient’s propensity to pay. These resources tap into patient financial data to better understand who is and is not likely to meet payment requirements, as well as those who may qualify for financial hardship assistance or Medicaid. Billing teams can leverage this insight to develop data-driven payment plans for those who are likely to meet payment obligations.

How are you addressing your biggest billing-related challenges?

Let us know where it hurts, and we’ll recommend a strategy that is sure to put you on the path to financial recovery.


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More About the Author:

Kelli Turner

Kelli Turner is the Director of Marketing Communications for ZOLL’s Data Division. She began her public safety career in 2001 as Communication, Public Affairs and Education Manager for the Virginia Department of Fire Programs, before joining ZOLL in 2006. Prior to ZOLL, Kelli served on multiple statewide task forces, was a member of the Joint Information Center Public Affairs team, and received numerous awards for her efforts in public outreach. Currently, Kelli focuses on helping Fire and EMS agencies utilize their data to make smart business decisions through educational efforts like ZOLL’s annual user conference (SUMMIT), educational webinars, and the ZOLL Blog.