Are out-of-town patients a problem? Here’s advice
Some payers are asking for bigger discounts
With the vacation-travel season at full tilt, hospital emergency departments (EDs) and some surgery centers are seeing their full share of seasonal business. But these patients aren’t necessarily thinking about health care. They’re more apt to focus on the cost of dinner and shopping.
They aren’t the only ones hunting for bargains.
Out-of-state health plans, it seems, are dickering over price more than ever when it comes to paying their vacationing enrollees’ medical bills, says Margaret Sabin, MHA, chief executive officer of Steamboat Springs (CO) Healthcare Association.
Individually, insurers are making tougher demands and asking for steeper discounts on the premise that these enrollees are costing them more by going outside the plan’s provider panel, Sabin says.
Don’t agree to discounts
But "without a contract, we aren’t obligated to accept any discounts," Sabin says. Her network, which includes Routt Memorial Hospital and its ED, sees 6,000 winter skiing-related injuries in a two-month period at the year-round Colorado resort.
For Sabin and outpatient providers in destination areas such as Steamboat Springs, out-of-state health plans’ demands are becoming a growing financial problem. In fact, the problem doesn’t end with tourists. Business travelers and retirees who relocate seasonally can pose the same reimbursement issues.
Some outpatient facilities are reportedly losing or foregoing thousands of dollars in unreimbursed claims.
But there’s a solution, observes Diana Contino, MBA, a principal with First Contact Medicine, an outpatient consulting firm in San Diego. No matter how unreasonable they may be with providers, health plans fret about losing enrollees to other health plans, especially enrollees who are well-off enough to travel.
These patients represent an ambulatory care center’s (ACC’s) strongest ally against an insurer’s demands, Contino says. "Write and encourage the patient to question why the plan won’t pay full charges," Contino says. The tactic works, she adds.
Here are a four additional out-of-network issues you might be tackling with an uncooperative payer and suggested solutions:
• Downcoding.
Reducing the level of medical necessity to justify a lower payment has become common practice with some out-of-area health plans, says Contino. The tactic commonly occurs at hospital EDs. Physicians there normally adhere to the five-tiered CPT-4 evaluation and management indicators for defining emergency cases.
If a payer downgrades the claim to a lower level, you can appeal the decision with documented evidence obtained from the attending physician. Or you can bill the patient for the unpaid difference and "nudge" the patient to pressure the plan into rethinking its decision, which may be more effective, Contino says.
• Balanced payments.
Shifting higher copays and deductibles onto patients has become common practice under managed care. Although many outpatient providers cringe at having to burden patients with higher out-of-pocket costs, getting them to foot part of the unpaid bill is necessity for out-of-network providers, Sabin says. If you’re charging these patients, continue to do so.
Strategically, the approach serves the purpose of helping to pressure the patient into making the payer more responsible for the full charges. If the health plan ultimately refuses payment, the patient is made responsible for the bill, and most vacationers have the means to cover minor emergencies, Sabin says.
• Payment barriers.
Out-of-towners don’t usually pose a problem for ambulatory surgery centers (ASCs). "Most patients don’t drop in for elective surgery," says Lisa Woodruff, business office manager at Goldring Surgical Center in Las Vegas.
But Columbia Surgical Park Center in Miami is an exception. The freestanding facility serves a large community of "snowbirds," retirees who relocate to warmer climates for the winter. The ASC repeatedly turns away cases involving commuter retirees, says administrator Steve Pierce, MBA.
The reason? Some out-of-state plans such as Detroit-based Blue Cross Blue Shield of Michigan generally refuse to pay for nonhospital-based services in Florida, Pierce says.
Pierce’s solution is to diversify his payer mix with plans that will pay at least part of billed charges. (The patient gets billed for the balance.) He’s also attempting to contract with out-of-state plans that offer enrollees point-of-service benefits.
• Preauthorization problems.
Loosening tight preauthorization rules in ambulatory care would greatly benefit out-of-network providers, says Sabin. Industry officials are closely watching the progress of two congressional bills endorsed by the Arlington, TX-based American College of Emergency Physicians (HR 815 and SB 238).
The measures would free patients of prior authorization requirements and force plans to cover and pay for emergency services based on the patient’s presenting problems, not the final diagnosis. "The change would greatly simplify the payment process," Contino says.
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