A Call to Action: “Humanizing” the Billing & Claims Experience

What patients see as one unified healthcare experience is, in fact, separate and distinct. What is needed is a fundamental rethink and redesign of the billing and claims process. Hospitals can play a key role in enabling this transformation, as can insurers.

Dan Sills

Associate Director at C Space

Dan Sills produces C Space’s customer experience podcast, Outside In, which The Huffington Post called one of “The 7 Best Business Podcasts You Should Be Listening To” and Entrepreneur included in a list of “Best Podcasts for Entrepreneurs.” When he’s not locked in an edit suite, Dan talks at Story Slams and was a 2016 grandSLAM finalist for cult storytelling circle The Moth.

With contributions from Anne Pessala, Amélie Touroyan, and Bethany Klaene.

Put yourself in this situation: It’s the weekend. Your young child is playing in the backyard, climbing an old oak tree, and you hear the crack of breaking branches. You rush your child to the nearest ER, where the intake nurse, doctor, and orthopedist pull out the heroics. They soothe both of you and distract your child from the pain while operating efficiently. It’s as great an experience as a broken bone could be. And it’s over… isn’t it?

Most of the time, the answer to that question is a resounding “no,” and what follows shows there is so much more to the story:

Three months later, you receive a bill in the mail for the treatment: $1460.45. Your stomach sinks as you realize you need to make sacrifices to cover the out-of-pocket costs. The billing codes are inexplicable and you suddenly fear that you are being billed incorrectly. So, you call your hospital, get transferred, and turned away. You call your insurer, and it’s a similar story. Several weeks and many phone calls later, some charges are removed, some remain, and you feel like the stress of repairing a broken arm was less disruptive than the process of paying for it.

The unfortunate truth is that the customer experience (for both patient and caregiver) is actually compartmentalized into a “health” and then a “billing” or “claims” experience. It’s true the professionals demonstrated real care in the exam or hospital room, but the complex billing and claims process that follows can transform this positive experience into a negative, stressful one that customers are often blindsided by and unprepared for.

What patients see as one unified healthcare experience is, in fact, separate and distinct, and organized to optimize “parts” of the process – not the whole. On one side, hospitals handle intake, treatment, discharge, and billing. On the other, insurers manage referrals, co-pays, claims processing, explanation of benefits (EOBs), and provider payment. It’s a complex, fragmented process characterized by handoffs, manual interventions and rules-based decision making. At its best, it is hassle-free for the patient. When there is a problem, it’s confusing, time consuming, and frustrating.

It’s so complex that many third party groups have sprung up, acting as mediators between treatment and payment, smoothing the process over and creating a financially predictable situation for the patient. Remedy helps patients with over-billing; Zest Health helps patients understand and get the most of out of their health benefits; Simplee creates a simple, engaging, beautiful payment experience for the patient. This might work in the short term and provide a much-needed service. However, they are a Band-Aid on a broken system, adding another layer of complexity to equation. If the system worked in a way that kept patients free from the issues that rise between the hospital and insurance company, there wouldn’t be a need for these kinds of concierge services.

What is needed is a fundamental rethink and redesign of the billing/claims process. We need a transformation that aligns more closely with the patients’ view of a unified experience, and is simplified, transparent and trouble-free. Hospitals can play a key role in enabling this transformation, as can insurers.

At minimum, hospitals could inform patients of treatment costs and what is covered/not covered/in network/out of network before services are rendered (or work with insurers to do so). They could make customer service for billing easier for people to access (why is it open only from 8-4 on week days only?) with helpful staff working on a patient’s behalf to solve the problem, not just take the payment.

Insurers also have the opportunity to elevate the customer service and claims function into a strategic asset for customer retention and satisfaction. They could transform call centers by training more staff in customer empathy and giving them access to the records they need in order to be good advisors. Like the hospital billing department, they too could offer to resolve the issue on the patient’s behalf – not force the caller to straddle provider billing groups and the insurer. They could redesign EOB’s to make them clearer, easier to understand, and written in consumer-friendly language. After all, the bottom line for the patient (consumer) is quite simple: is it all taken care of? If not, how much do I have to pay, and why?

The biggest impact for improved customer experience and reduced complexity will only happen through collaboration of hospitals and insurers and others to simplify billing codes, restructure plan and payment levels, reduce handoffs and diminish the potential for human error. A deliberate redesign of the whole experience is necessary – one that creates synergies across the system instead of points of friction, or increased pain. Making progress against this goal is challenging and essential, especially in the current climate of change and uncertainly around future of healthcare. It’s time to upend a system that is ripe and long overdue for disruption, thereby allowing patients to focus on their broken bones, not a broken billing system.

You may be interested in:

Generation Wealth

Generation Wealth Looking back at the ostentatious tribes of the early 2000s   By Lauren Greenfield, Director of Award Winning Ad Campaign “Like a Girl”, anthropologist and writerLAUREN GREENFIELD/INSTITUTE Xue Qiwen, 43, in her Shanghai apar​tment, decorated...

The Renaissance of “Me”

The Renaissance of “Me” By Franco Bonadio, Managing Partner, Human TruthsBill Alberti, Managing Partner, Human TruthsMachiko Wilson, Associate ConsultantBy default, we tend to look at one thing as “better than” another. It doesn’t really matter what it is. You can...

Introducing the Express Arena

Introducing the Express Arena By Jessica DeVlieger, Global CEOA surprising new behavioral trend has been observed in the UK; British people - a nation famously obsessed with class - are starting to hide their privilege.In January 2020, Sam Friedman, a sociologist at...

Rebuilding Women’s Health from the Patient Up

Reimagining Women’s HealthThe world of women’s healthcare is primed for disruption, at least if you’re talking to the women who comprise the market of this $10B*+ industry – and we are. In this report, we reimagine women’s healthcare with everyday women leading the...

From push to pull

From push to pull Jessica DeVlieger, Global CEOHow do you move your brand from push to pull?You communicate at eye-level.You speak to people’s souls.You act more human.You become more relevant.Push marketing has been stuck in controversy for some time. Consumers'...

Mary Barra, Chair and CEO, General Motors: On The Road to an All-Electric Future

Mary Barra, Chair and CEO, General Motors: On The Road to an All-Electric FutureSubscribe to the Outside In podcast: At the beginning of 2021, Mary Barra, Chair and CEO at General Motors, set an ambitious goal for the legendary automaker: end tailpipe emissions from...

John Kotter, Harvard Business School: The Principles, Practices, and Science of Change

John Kotter, Harvard Business School: The Principles, Practices, and Science of ChangeSubscribe to the Outside In podcast: Change is hard. And it never stops. The volatility, speed, and uncertainty that comes with change has been increasing exponentially over the past...

Pam Lifford, President, Global Brands & Experiences, Warner Bros.: Fans and the Power of Listening

Pam Lifford, President, Global Brands & Experiences, Warner Bros.: Fans and the Power of Listening Subscribe to the Outside In podcast: Harry Potter. Batman. Looney Tunes. Game of Thrones. Each of these iconic franchises has shaped popular culture for years....

Reshma Saujani: Fighting for Gender Parity and a ‘Marshall Plan for Moms’

Reshma Saujani: Fighting for Gender Parity and a ‘Marshall Plan for Moms’Subscribe to the Outside In podcast: Reshma Saujani founded Girls Who Code in 2012, with a mission to close the gender gap in computer science and educate and prepare girls for careers in the...

Franklin Leonard: The Black List That’s Changing Hollywood

Franklin Leonard: The Black List That’s Changing HollywoodSubscribe to the Outside In podcast: Before “Argo,” “Juno,” “Slumdog Millionaire,” and “The King’s Speech” became some of the most successful films in Hollywood (and subsequently went on to win Oscars), they...