A new study by the health care system reveals a significant gap in consumer healthcare rights. Despite attempts to curb surprise medical bills, a large portion of insured Americans are still receiving unexpected charges. Adding to this problem is the high rate of coverage denials, leaving patients with substantial out-of-pocket costs and causing financial hardship
Study Reveals Low Contestation of Surprise Medical Bills:
The study found that less than half of those hit with surprise bills actually contested them, and even fewer appealed denied coverage. The researchers suggest that improving health literacy is crucial to empower patients to effectively navigate the healthcare system and challenge unfair billing practices.
The data for this study was collected from over 5,600 insured adults by SSRS between April and July 2023.
The survey revealed that nearly half of participants encountered unexpected medical bills. Those with individual or marketplace plans were most likely to report these surprise charges, while Medicaid beneficiaries were least affected.
Despite facing unexpected costs, less than half of those affected disputed the bill. Individuals with Medicare, Medicaid, or Hispanic backgrounds were more likely to contest charges, as were those with higher incomes.
Medicare Beneficiaries Most Successful in Challenging Medical Bills:
Medicare beneficiaries who challenged their bills had the highest success rate in reducing or eliminating charges, followed by Medicaid recipients. Employer-sponsored health plan members had the lowest success rate. Simplifying the dispute process, particularly for public insurance programs, could benefit consumers.
Young, low-income Hispanic adults were most likely to accept unexpected medical bills without dispute. Data revealed that 60% of those who didn’t challenge their bills were aged 19-34, while 58% had low incomes and 59% identified as Hispanic. The primary reasons for inaction were a lack of awareness of patient rights (54%), the perceived insignificance of the amount (29%), time constraints, and uncertainty about appeal processes.
Beyond unexpected bills, patients frequently reported coverage denials for medically necessary care. Seventeen percent of participants experienced such denials across all insurance types. Despite these challenges, a notable proportion (43%) of patients or their doctors appealed these decisions. Private health plan members were slightly more likely to challenge denials (44%) compared to those with public plans (40%).
The Severe Impact of Coverage Denials:
Coverage denials had severe consequences for patients. Nearly six in ten respondents experienced delayed care, while eight out of ten felt increased anxiety. Almost half saw their health worsen, and one in six reported their condition escalating to a more serious level. Only a small percentage reported no impact.
Many patients did not appeal surprise denials due to lack of awareness of their rights (45%), uncertainty about who to contact (40%), or time constraints (23%). However, for those who did appeal, half were successful, with varying degrees of approval.
To address this issue, researchers suggest HHS track claims denials and policymakers implement penalties for improper denials or billing. Additionally, raising public awareness about appeal rights and offering support during the appeals process could benefit patients.
Allzone MS: Value-Based Care and Its Impact on Billing
Value-based care (VBC) represents a significant shift in the healthcare industry, moving away from the traditional fee-for-service model towards a system that rewards providers for the quality and efficiency of care delivered, rather than the quantity of services provided. This transition has profound implications for medical billing.
Value-Based Care and Its Impact on Billing
Value-based care (VBC) represents a significant shift in the healthcare industry, moving away from the traditional fee-for-service model towards a system that rewards providers for the quality and efficiency of care delivered, rather than the quantity of services provided. This transition has profound implications for medical billing.
The Role of Medical Billing Companies in VBC
As the healthcare landscape evolves towards value-based care, medical billing companies play a pivotal role in supporting providers navigate the complexities of this new model. By offering specialized expertise in VBC reimbursement, data management, and revenue cycle optimization, these companies can be instrumental in ensuring providers’ financial success.
How Value-Based Care Impacts Billing
Shift from Volume to Value:
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- Focus on outcomes: Instead of billing for individual services, providers must demonstrate the value of care delivered by measuring and reporting patient outcomes.
- Complex reimbursement structures: VBC often involves bundled payments or capitation, which require a different approach to billing and revenue cycle management.
Increased Data Collection and Reporting:
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- Quality metrics: Providers need to collect and report data on various quality measures to meet the requirements of VBC contracts.
- Risk adjustment: Accurate patient data is crucial for risk adjustment models used in some VBC arrangements.
Advanced Analytics:
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- Predictive modeling: Analyzing patient data can help identify high-risk patients and tailor care accordingly, impacting billing and revenue.
- Cost-benefit analysis: Understanding the cost of care and its impact on patient outcomes is essential for financial success in VBC.
By partnering with us, providers can effectively manage the challenges posed by VBC, optimize revenue, and focus on delivering high-quality patient care.