Think of the payment assurance that Best Buy has in a payment transaction: it allows a consumer to walk out of its store with a thousand-dollar television, even though the payment is not yet in the company’s bank account in the form of available funds. The only thing Best Buy has to fall back on is its trust in an authorization, delivered by a payments network, after a consumer’s payment card is processed. Imagine telling Sam Walton in 1960 that he’d just have to trust that the money owed to Walmart would be in the bank. Yet this concept is what healthcare needs: the concept of trust, payment assurance and the efficiency for the provider and the payer to transact money.
The healthcare industry needs to develop a new technology and operating model that can deliver payment assurance to providers and simplify the payment experience for payers. This new model should be built on top of the healthcare industry’s existing infrastructure of technology, process and compliance.
The new model for payment assurance includes the following:
At the point of service, providers must:
1. Assess eligibility and benefits, accumulators and financial capability through standard transactions triggered by front office software and/or health plan identification cards.
2. Apply fee schedules, eligibility data, financial data and other programs such as charity.
3. Establish expectations with patients by estimating the expected patient responsibility and communicating payment terms, timing, notifications and process.
Leveraging this information, providers must support all payers, all banks and all cards, as well as the ability for patients to pay online and make payment arrangements.
Additionally, providers must have access to an integrated electronic claim submission and claim status gateway that features timely adjudication and real-time information, as well as an 835 that is reconciled and linked to an electronic funds transfer for the payer’s responsible portion of the claim. This payment must be made to the bank account of the provider’s choice, in a timely manner.
Once services are rendered, providers must:
4. Collect any known patient responsibility and/or pre-authorize the patient’s preferred payment method.
5. Submit the claim.
6. Upon claim adjudication and receipt of the 835 from the payer, trigger an automated payment to get a direct deposit of the exact patient responsibility from the patient’s preferred payment method.