(In this second part of a two-part series on price estimates, we discuss factors that can lead to incorrect estimates. In last month’s issue, we discussed how two facilities used estimates to dramatically improve collections.)

If a procedure or surgery ends up being slightly different than it was expected to be when a price estimate was provided to a patient, this difference can cause major problems for the patient and the facility.

“Small changes in care can yield big changes in expense to the patient,” says David Kelly, MHSA, director of revenue cycle at Mary Rutan Hospital in Bellefontaine, OH. Sometimes a surgical procedure simply takes longer than expected.

To address the problem of incorrect CPT codes, leaders at Novant Health in Winston-Salem, NC, met with leaders in the surgery scheduling department. “They now get the code that the surgeon is authorizing and place it in a field in the system that lets us know what to price,” says Craig Pergrem, MBA, senior director of revenue cycle, pre-service, financial counseling, and onsite access.

Patient access leaders worked hard to achieve a collaborative relationship with clinical areas to ensure the correct CPT codes are obtained. “An informed patient who knows what to expect ahead of time, whether they pay prior to service or not, is better off by not receiving that surprise bill after their service,” says Pergrem.

Reasons for mistakes

Failure to obtain correct procedure and diagnosis codes, or the frequency and dosage for infusion or injectable drugs, are two common reasons for incorrect price estimates given to patients at Salt Lake City, UT-based Huntsman Cancer Hospital. “We end up billing with different codes from the ones we used for estimates,” says Junko I. Fowles, CHAA, supervisor of patient access and financial counseling. A colonoscopy is sometimes billed as a diagnostic procedure instead of a screening examination. “Therefore, the patient’s plan processes the claim differently,” says Fowles. Medicare patients might think they are receiving a free screening colonoscopy, but if a polyp is found, the procedure changes to a diagnostic procedure with biopsy. In this situation, the patient has a 20% copayment.

For more than a year, Huntsman Cancer Hospital’s patient access areas have used a price estimate tool for all scheduled services, except transplants and cosmetic services. “We have been very successful providing accurate service estimates to our patients,” reports Fowles.

These are factors

These two factors sometimes lead to incorrect estimates:

• Incorrect service location and patient status, whether clinic, outpatient, day surgery, observation, inpatient, or emergency department.

In terms of the patient’s insurance coverage, “there may be some variation for inpatient or observation services compared to outpatient services,” Fowles explains.

• Inaccurate insurance payer and benefits information.

“Our estimates are calculated based on the historical allowed amount data,” explains Fowles. “For some plans, the allowed amount is higher than our billed charges. Therefore, coinsurance is miscalculated.”

If patients end up being billed much higher than the quoted estimated amount, the case is escalated to direct supervisors and managers for resolution.

In this scenario, says Fowles, “each estimate is reviewed case by case. Supervisors or managers may approve additional discounts on the self-pay balance.”