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

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.

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