Because of the Affordable Care Act, many people received health insurance who never enjoyed it before. Some assumed it would pay their healthcare costs in full. “The registrar says, ‘You owe $2,500,’ and the person says, ‘What? I have insurance,’” says Rick Gundling, senior vice president of healthcare financial practices at the Healthcare Financial Management Association.

Many people do not understand the meaning of basic terms such as “copay” or “deductible.” This soon becomes apparent when registrars try to talk to patients about their bills. Patient access employees need two things to talk about money with patients: empathy and training, according to Gundling. Many people bought health insurance without any education at all on what it covers. This is true whether the patient received coverage through an employer or purchased it online through their own means. “Registrars have to realize they’re probably the first person to talk about insurance with the patient,” Gundling offers.

Despite growing attention to the topic by policymakers, it is still unclear if price transparency factors into which hospital people choose. “We are still trying to understand how transparency affects medical decision-making. It may not make a big difference at all,” Gundling notes.

A person who needs knee surgery might go where their neighbor went for a similar procedure. Many people just choose the closest hospital, the one that is in network, or where their doctor has privileges. It is even possible that people will choose a hospital with higher costs if they view it as better quality for some reason. If a friend enjoyed a great surgical outcome, that might signal high quality in the eyes of the patient. “The patient might be willing to pay more to go to that hospital,” Gundling offers.

Before patients can pick and choose hospitals with cost in mind, they need to be able to compare prices. Gundling recommends hospitals provide pamphlets on healthcare prices, how to avoid surprise bills, and what it means to be in network. Patients can be in network with the physician group, the hospital, and the surgeon — but not the anesthesiologist. “Now, they get stuck for a $1,000 bill they were not expecting, and they didn’t even know to ask that,” Gundling laments.

People who use mobile apps to buy everything from groceries to cars are baffled that they cannot do the same with medical care. Confusion breeds mistrust. “Patients don’t understand why it has to be so convoluted,” Gundling explains. Even two people with the same insurance who will undergo the exact same procedure can end up with dramatically different bills. For instance, two knee surgeries can cost vastly different prices because one person experienced unexpected complications.

Meanwhile, revenue cycle leaders are keenly aware that the financial side of care affects overall satisfaction, not usually for the better. Clinicians are ethically obligated to respect patients’ autonomy, right to shared decision-making, and religious beliefs. “We need to also respect them financially,” Gundling adds. “Patients don’t necessarily want a treatment plan that’s going to impoverish their spouse or family.”

This is much easier for elective, scheduled services. Yet, the highest costs occur on the inpatient side, where care sometimes is unanticipated. This makes conversations exponentially more difficult. “People are not feeling well and are very anxious. It’s probably the worst time to talk about money, but there you are,” Gundling says. The alternative (and long-standing practice) is not to mention money at all while the patient is in the hospital. This means a surprise bill when it is too late to plan or delay care. “Once patient access tells them what is covered, there might be a different treatment option,” Gundling says. For some, a zero-interest loan takes the pressure off. Some good detective work by registrars might reveal that half the patient’s deductible was met recently, lowering a quoted $5,000 out-of-pocket cost to half that amount. “That’s where technology can help,” Gundling says.

One frustrating obstacle is that payer systems do not interface with hospital registration systems. This makes updated information hard to come by. “We are definitely going to see greater strides toward interoperability where all these systems can talk to each other,” Gundling predicts.

Whatever tools, systems, and training are in place, financial conversations require a personal touch. This is where revenue cycle employees come in.

“There’s still an expectation that you can have a conversation with someone,” Gundling says.