Ask the Experts: Price Estimates
What points should a hospital or medical group consider when generating a pre-service estimate of patient responsibility for patients with traditional Medicare coverage? Do these points change if the hospital or medical group requests payment of that estimate prior to service delivery?
Answer 1: I am making the assumption that this question is related to outpatient services, because inpatient hospital services for Medicare patients only carry the Part A deductible liability, and depending on days utilized, the co-insurance and lifetime days daily copayment amounts.
The trick with giving patients an estimate for outpatient hospital services is that patient liability is based on the ambulatory payment classification (APC) payment, not the charges. Of course, any lab tests are on the fee schedule and do not carry a copayment. Unless you have a way to determine what the APC payment would be, it’s nearly impossible to give the patient an accurate estimate of liability.
Our organization has elected not to try, and we bill the patient after Medicare makes their payment. The vast majority of our Medicare eligible patients have some form of secondary coverage, either supplemental plans or Medicaid.
This question was answered by: Brenda Loper, regional director of access services for four Sentara Healthcare hospitals.
Answer 2: Estimates including physician services become much more complex and you need to ensure the appropriate CPT codes are provided and that all services are included (i.e., anesthesia, radiology, pathology, and the surgeon or proceduralist). We have developed a process, but it needs continual refinement and fine tuning.
It should be noted that the vast majority of our Medicare patients do have a supplemental plan that covers the deductible and copayment amounts.
This question was answered by: Matt Levsen, CPA, FHFMA, associate CFO, University of Missouri Health Care and a member of HFMA’s Show-Me Missouri Chapter.
Answer 3: For outpatient services, our price estimator calculates the APC based on the primary CPT code and gives the national standard co-insurance. Representatives can then add the deductible if that is due as well. This process can get complex because there can be multiple CPT codes with associated co-insurance for the same account, but I believe there is a federal guideline that if a patient asks for an estimate, a provider is obligated to provide one so providing one at least at a high level is a great start.
This question was answered by: Suzanne Lestina, FHFMA, CPC, vice president, client innovation, AvadyneHealth and a member of HFMA’s First Illinois Chapter.
Answer 4: Traditional Medicare coverage out-of-pocket estimates are the easiest. As others have said, the out-of-pocket is likely small if there is secondary coverage or Medicaid.
If there isn’t secondary coverage, then an algorithm based on finding previous Medicare patients with similar treatments is the best approach. This is easier than other payers because the approved amounts are set, so the 20 percent that the patient owes is likely more consistent than for the many individual variations of private plans. There will be less variation from previous averages, leading to a more accurate estimate.
Note that we don’t collect up front from Medicare patients. We give estimates to anyone who requests them, so my comments relate to those types of estimates done on request.
This question was answered by: Ruth Lande, vice president, patient revenues, Memorial Sloan-Kettering Cancer Center and a member of HFMA’s Metropolitan New York Chapter.
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