Patients’ high expectations for self-service price estimators are not aligned with what hospitals actually can offer. In an instant gratification world, patients want price estimates to be readily available like so much other data. “Estimates are one of those things that appear, from the outside, to be really easy,” says Debi Lasswell, manager of revenue cycle solutions at Bluetree Network.

Patients make comments like, “How much is a hip replacement? Isn’t there a price list somewhere?”

“Healthcare billing hasn’t caught up to consumerism’s demands for accessibility and transparency yet,” Lasswell says. “It’s certainly one of the quality gaps that’s most frustrating to patients.”

Most hospitals do not offer price estimates proactively; thus, perhaps this is why CMS intervened with its transparency rule that went into effect on Jan. 1. (See this issue’s cover story for more information about that rule.) “There are a lot of concerns about inaccuracies,” Laswell explains.

Hospitals cannot really rely on their insurance verification tools and accuracy of contracted prices to give exact estimates, even if it is handled by trained staff. “There is still fairly widespread trepidation about what it will mean for patients to generate their own estimates,” Lasswell says.

Pitfalls of DIY Research

If patients cannot avail a hospital-provided self-service price estimation tool, can they turn to insurance providers for cost predictions? Depends on their state of residence. Only six states mandate price transparency from carriers, providers, or both.1

But even in a state like Massachusetts, where providers must give consumers the price of any procedure within two business days (if requested), patients may be unaware of those laws. (See the story "Consumers May Be Unaware Price Information Is Available" in this issue.)

While conducting their own research, patients may select an incorrect plan or enter the wrong CPT codes. Even if they enter it exactly right, CPT codes could change for clinical reasons, and the patient would have no way of knowing it. “These days, just one drastically miscalculated estimate can lead to viral media content or a slew of negative online reviews,” Lasswell says.

This worry means self-generated estimates are not yet a reality. “It’s something that hospitals want to roll out when they know they can do it right, and not before — despite the resounding consumer demand for them,” Lasswell says.

Answer the Why, Provide the How

If patients ask, “Why can’t I just calculate my own estimate?” Lasswell suggests this response: “Estimates are a little tricky. We need to make sure we take different insurances and benefits into account. Estimates can be somewhat tough to generate accurately. We’re working toward making price estimates more easily available. In the meantime, you can call this number: XXX-XXXX. The staff there can help make sure you receive an accurate estimate.”

Many hospitals currently review benefits and cost at the time of service or during preregistration. “However, patients are looking for a more hands-on approach. Patients like the ability to complete their own estimates through a self-service option,” says Tara Richardson, vice president of patient access at Cincinnati-based Ensemble Health Partners.

Patients want self-service options for scheduling, registration, and form completion. They also want to see potential cost implications for upcoming visits. Some patient access departments use a third-party, freestanding estimate tool — but it probably is not integrated with their registration system.

“However, it could provide support and assistance for the patient to price-shop for potential services,” Richardson offers.

Of course, self-service estimates are not worth much if they are incorrect. Procedure codes and benefits all have to be spot-on. “If any of these items are not identified appropriately, the estimate runs a risk of being inaccurate,” Richardson cautions.

Certain procedures carry additional costs outside the main procedure (e.g., medications or lab work might be needed for a radiology procedure). Contract details also need to be pulled into the estimate. “If this is not accurate, or does not supply a contracted amount, the overall cost of the services can be drastically overstated,” Richardson says.

REFERENCE

  1. Pioneer Institute. National study finds most states lack healthcare price transparency laws. May 7, 2020.