Tips for Hospitals Navigating Surprise Billing Among Patients Receiving Care Amid the Pandemic

Gordon Jaye, vice president, hospital operations, and Matt Simon, director of on-site partnership, both for PatientMatters, provide tips for hospitals to support patients who receive a surprise bill, and discuss how health plans have changed their policies throughout the pandemic and highlight the some of the greatest challenges hospitals face in regards to surprise billing.

More about the speakers:

Gordon Jaye

Gordon Jaye has worked in healthcare delivery systems, information technology, and physician practices for more than 25 years, most recently in leadership positions. As Vice President, Hospital Operations at PatientMatters, Gordon’s expertise is in delivering superior patient experiences, revenue cycle management, process optimization and automation, and managing hospital mission-critical services to PatientMatters and its healthcare customers. 

Matt Simon

Matt Simon is Director of On-Site Partnership for PatientMatters where he is responsible for the strategic oversight of patient access, patient financial services, and revenue cycle integrity for various client healthcare facilities throughout the United States. His specific areas of expertise include EHR revenue cycle optimization, revenue cycle technologies and operations integration, and staff onboarding programs that emphasize the role of patient financial care.

Podcast Transcript:

Integrated Healthcare Executive:  Welcome back to "Pop Health Perspectives," a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population management and more.

Today we are joined by Gordon Jaye, Vice President of Hospital Operations and Matt Simon, Director of On-Site Partnership, both for PatientMatters.

They provide tips for hospitals to support patients who receive a surprise bill and discuss how health plans have changed their polices throughout the pandemic and highlight some of the greatest challenges hospitals face in regards to surprise billing.

Gordon Jaye:  Good afternoon, I'm Gordon Jaye. I've been with PatientMatters for six years. I'm the Vice President of Hospital Operations.

My normal duties include engaging clients on the front end, making sure all of their contractual agreements are met, helping our clients reach their goals of increasing patient satisfaction, which also, obviously, includes the need to eliminate or reduce surprise bills, which is what we are focused on today.

Prior to joining PatientMatters, I spent several years at Eskenazi Health in Indianapolis, which is one of the largest safety net hospitals in the country. My role there was as a Director of Patient Access and Financial Eligibility. Under my jurisdiction, was also the ACA Navigator Program, which is part of what's commonly known as Obamacare, and also the county charity program.

Prior to that, I spent several years in various roles at Sutter Health in California. As you can see, I've spent the majority of my adult life working in healthcare, primarily on the provider side, and then the last six years spent on the vendor side with PatientMatters.

Matt Simon:  Hello, everyone. My name's Matthew Simon. I serve as the Director of On-Site Partnerships at PatientMatters.

In my role, I'm responsible for the strategic oversight of patient access, patient financial services, and revenue cycle integrity for various healthcare facilities throughout the United States.

I have over a decade of healthcare experience with expertise in EHR revenue cycle optimization and staff onboarding programs that emphasize the role of patient financial care and patient financial communication.

Before joining PatientMatters, I served in various roles along the revenue cycle for Acute Care Hospitals located in New York where I managed charge capture, claims submission, accounts receivable, and denial management operations.

I held various revenue cycle leadership positions comprising of patient access, contract management, financial analysis, and even cost accounting functions.

Integrated Healthcare Executive:  On a more broad scale, can you discuss how health plans have changed their policies throughout the pandemic? How does this impact surprise billing? What are some of the most important things to know about surprise billing?

Gordon:  With surprise billing, that's a topic that's now on every state's (and even on a federal level) radar. There has been legislation that has been crafted locally and on a state level for quite some time.

Just recently, Georgia passed their version of the surprise bill law, which helps eliminate some of the burdens that get placed on a patient when the patient presents to the emergency room that is not part of their plan.

During COVID, some of those requirements and stringent rules around places of care have been waived. Certain procedures, as it relates to directly with COVID, don't require prior authorization.

Some payers have gone even as far as assuring their enrollees that any cost associated with COVID that has to do with admissions, and testing, and treatment...all of those things have been waived for certain select plan members.

More broadly, as a consumer of healthcare, you need to check with your local providers of care and with your insurance health plan to see what changes, if any, have been made to your benefits as it relates to COVID.

COVID does present a unique opportunity for hospitals to engage their patients as it relates to surprise bills. Patients are now presenting with additional anxiety, afraid to come to the hospital. We've all seen that, although the restrictions around COVID for certain states had been lifted very recently, now that we're in the second phase of the first wave.

Nonetheless, there have been some changes made to how hospitals are onboarding their patients. That may result in some surprise bills.

The way that institutions are handling that is unique in making sure that all of their patients, not just COVID patients but all of their patients, are fully informed prior to service so that to try to eliminate a need for a surprise bill discussion post-treatment.

Matt, I don't know if there's anything you wanted to add on to that, as well.

Matt:  Sure. What I'll add, just for how health plans have changed policies due to the pandemic, there's also been an increased utilization in telehealth, which is very important to keeping patients, especially those most at risk, from having to travel and potentially putting themselves at jeopardy of exposure.

We've also seen some policy changes where the payers are easing the prior authorization requirements when it comes to the COVID-19.

Going back to the waiving of the cost share that Gordon was mentioning, with the Family First Coronavirus Response Act that was passed back in March, it does require health plans to pay for testing and not pass any of that cost on to the patients. All that testing still needs to be deemed medically necessary.

Obviously, patients aren't always involved in that determination. It still is a gray area. I think patients, when it comes to a surprise bill, need to be careful of medical necessity, but also some patients do not have out of network benefits. If not, then they may be responsible for any copays, deductibles, or coinsurances despite that act being passed by Congress.

Gordon:  One of the things that I wanted to mention, Matt, is that obviously pertains to patients that are covered. What about our self-pay, uncovered, underinsured population?

The Trump administration, early on during COVID-19 did pledge that they would cover individuals that did not have any health coverage, whether it commercial or otherwise. That they would cover those patients, get tested, and if necessary treatments. Those that were not covered by any insurance.

As to where the finally landed and how it has been put into operations at the hospitals, it's hard to say because there hasn't been very much clarity on that. Early on in the pandemic there was that pledge from the White House, that they would indeed cover some of those. Obviously, that eliminates the burden financially or the need for a surprise bill discussion for that population.

Matt:  Great point.

Integrated Healthcare Executive:  How can hospitals work to ensure patients do not receive a surprise bill?

Gordon:  From a hospital perspective, that has been a struggle for a very long time. Hospitals are good at providing service. They are good at sending statements, but not necessarily identifying the cost preservice.

Many of our clients have engaged over the years with us that use technology as an enabler of some of that work. Using technology to identify what the true out of pocket cost is going to be that's individualized and personal to the patient's benefit package from their insurance coverage.

Taking advantage of some type of technology, having a robust work flow that identifies the cost for the patient up front, and then, also, then provides the payment options to the patient so that the burden of not knowing...

It's one thing to know what the cost of something is. It's another to have the ability to be able to pay for it. Giving patients financial options of how you can meet some of those burdens. Also, utilizing internal programs, such as charity programs, that the patient may be qualified for.

We look at it more broadly than just helping eliminate or reduce surprise bills. We look at it...How can we not even burden our patients with a bill to begin with?

The ways to do it is, some of the ways that I mentioned, is using a center that is dedicated to educating patients on their benefits package, identifying the true out of pocket cost, and then providing them some payment solutions to get to that point.

Matt, if there is anything you want to add as it relates to once the patient does have it, is burdened with a surprise bill or something of that type, how do you handle it for your clients?

Matt:  What we always recommend for hospitals is having some sort of service recovery program. If a patient receives what they would deem a surprise bill, you don't want to allow these complaints to fall on deaf ears.

You want to make sure that you set up a process that someone internally handles the complaints, reviews where that breakdown in communication came from, gives an explanation back to the patient.

Then, of course, review anything, just to make sure that that surprise bill is accurate and that he patient is receiving that correctly, and that there wasn't some other breakdown in the billing process where maybe the patient had coverage and the hospital just failed to identify it up front.

What I'm surprised to hear is that with some hospitals, they think patients don't understand all the different terminologies that insurance companies use. What we find is that patients are, in fact, very educated. That understand that they will, of course, owe something towards their service.

We always encourage hospitals to not shy away from that communication and give as much information as possible, especially on the front end of revenue cycle. This is to avoid any surprises in the back end when it comes to the billing.

Integrated Healthcare Executive:  Do you have any tips for hospitals to support patients who receive a surprise bill?

Gordon:  Yeah. I think the best thing to do is engage the patient. When the patient calls the hospital and is somehow distressed by a statement they have received, clearly because they were not identified the cost of that service prior to it being rendered, the tip to the provider is to engage with the patient and explore all the options. All the options that may be available to that patient.

The patient may be a good candidate for some kind of a Medicaid expansion program, may be a candidate for your charity program, could be a great candidate for a hospital sanctioned payment plan and if you're offering solutions like a zero interest medical loan.

There are so many different instruments that are available to help the patient. Fully understand the patient's financial standing during this difficult time. There's a lot of folks, as we all know, that have little to no savings on any given day and that COVID has simply made that matter worse.

As the guidelines for Medicaid or for any other programs change, it's important for the provider to continue to educate their patient population on all of the options that are available and not simply default to a statement and wait for a payment to come in.

We always encourage patients to get involved early, but also for the providers to have a mechanism in place to identify these patients that potentially may have been subject to a surprise bill and reach out to those patients proactively instead of waiting for a complaint to roll in.

Integrated Healthcare Executive:  What are some of the greatest challenges hospitals face in regards to surprise billing? How should they address those challenges?

Matt:  Gordon has mentioned technology before, but I believe that that is one of the greatest challenges for hospitals because there is an investment that the hospitals need to make in order to address a surprise bill.

This technology, this investment, includes such tools as an eligibility verification, medical necessity software, an estimation calculator. Of course, if you're going to financially clear the patient to make sure that not only will the hospital get paid, but also that burden doesn't fall on the patient, then we would also recommend some sort of authorization engine to both check status of or obtain precertification on behalf of the hospital.

Gordon:  I would add to that, Matt, that understanding and identifying the patient's responsibility is important, but I would think also equally important is understanding the patient's ability to pay. Do they have the financials, the wherewithal, to absorb that type of a cost to them?

Using something like a propensity to pay data or something that's an enhanced version of that. Using something that helps you understand what the patient’s current financial state is.

We all know that when we encounter health systems or just public at large, we are very uncomfortable as consumers discussing our financial obligations and also how much we have in our savings. What kind of cost can we absorb?

Having technology that the patient has consented to as part of their treatment, having access to that data that Matt alluded to with estimation and eligibility, if they have coverage, or with propensity to pay information. It helps us get a more holistic look into the patient's financial standings and be able to craft a solution that can best meet their needs.

I think it's important to be able to not only identify the cost of care, but also be able to understand the patient's ability to pay and then crafting a solution to meet those needs.

Integrated Healthcare Executive:  Is there anything else that either of you would like to add?

Gordon:  I would add, for the patient, if you do get a surprise bill please do not ignore it. Don't wait for multiple statements to come your way before you have a reaction to it. Call the hospital directly. Engage with your healthcare provider's office. Come up with a suitable plan to meet your responsibilities.

That helps you. That also helps your provider meet their mission. I think, for both parties to work together is probably the best advice I can give. For the patient, most importantly because if you ignore these statements, ultimately, they may end up with a debt collector that could potentially damage your credit and create distress even further.

You certainly don't want to ignore the bills that might come your way, but also engage with your provider and have a discussion to see if you can negotiate the prices down. Is there a way for the provider to provide you some additional credits so that your responsibility is reduced? Is there a program that you can take advantage of?

Explore all your options. Ask all the questions. Challenge the bill if there is something on the bill that you don't recognize or don't understand. Ask questions around them. Make sure that it is accurate, that it reflects your experience that you had with your care and that there is nothing erroneous on it.

Make sure the bill is accurate. Engage with your provider's office. Try to explore all of the options that are available to you before you simply ignore your responsibility. That would be my advice.