Giving patients estimates: Is this a two-edged sword?

Information may be 'confusing and misleading'

Currently, Methodist Le Bonheur Healthcare in Memphis, TN, is "in the infant stage" when it comes to being able to quote prices to patients through its web site, says Jessica Murphy, CPAM, corporate director for patient access services. "But we have done a good bit of research, and believe when we do this it will be a useful product," she says.

The primary reason that the hospital has not yet implemented a point-of-service pricing system available through its web site is that it can be a "two-edged sword," says Murphy.

"Transparent or point-of-service pricing can be very helpful from a customer service aspect, but can also be confusing and misleading," says Murphy. She gives these examples:

If a person is "self-pay" and trying to budget a health care need, the charges shown for services would not reflect any type of self-pay discounting or income-driven charity pricing considerations. 

If the person is covered by commercial or managed care insurance, the actual out-of-pocket expense to the patient depends on the contractual considerations much more than the "charge" for a service. 

Another issue centers around the fact that many health care services don't have "set" charges but, instead, depend on acuity or amount of time and types of resource needed to diagnose or treat the problem. 

At this time, patient access staff handle pricing requests by phone or in person using information from the patient's physician, charge averages, and estimates or specific charges linked to procedural and diagnosis codes. 

"We have designated management team associates who handle these requests and speak with the patients or family members," says Murphy. "This allows special considerations around charges or out-of-pocket expenses to be discussed in a two-way dialogue."

Discussions can 'end badly'

Giving patients inaccurate estimates is one potential pitfall. "We have found ourselves in this untenable situation more often than we would like," says Murphy. "The fact that there are so many variables to take into consideration is a primary reason why price discussions can end badly."

What a physician orders and what is subsequently determined to be what the patient needs can have a significant impact on the charge for services. Other medical conditions a patient has can adversely affect the time or resource needed to diagnose and treat a problem, thus affecting the charges for the services rendered. 

"As we often have to remind ourselves, this is not like going to the corner market and buying a half gallon of milk, where you clearly see exactly what you will pay and there is no room or need for further discussion," says Murphy.  

Murphy extends that analogy to add that if a consumer goes to the register and the milk does not scan for the same amount that was posted, the customer will be angry, distrustful, and want to have the problem resolved immediately. Inaccurately quoting a price for health care services leaves everyone in that same situation, but the dollar amounts are likely to be significant. "This creates a much more intense situation than experienced at the sales register," says Murphy.

Murphy says she feels that designating a small number of people to handle these pricing inquiries lessens the chances of miscommunication. 

Patient access staff work with scripting as much of the expected conversations as possible, carefully stressing words such as "estimate" and "based on information available to us today."

"Having conversations around the pricing estimates and expected out-of-pocket expenses requires patience, excellent communication skills, and attention to detail," says Murphy. "Rarely can these conversations be quick and easy. Using good judgment in selecting the persons authorized to handle these requests is the key to effective price quotes and increased patient satisfaction."

Although providing a front end payment expectation is very effective in increasing point-of-service collections, Murphy says that this, too, carries the potential for dissatisfaction and misunderstanding. 

"We work with carefully prepared matrices for our primary managed care contracts which define for patient access a reasonable amount to collect," says Murphy. "We try to collect nearly all of what we expect the patient will pay but not overstate that amount and find ourselves constantly having to refund overpayments."

In addition, the hospital has a clearly stated policy to address self-pay discounts. "We have developed a good process by which the need for charity care can be evaluated and approved in a short amount of time, allowing the patient to be treated with dignity and respect as we provide the medical care he or she needs," says Murphy.

[For more information, contact:

  • Jessica Murphy, CPAM, corporate director for patient access services, Methodist Le Bonheur Healthcare, Memphis, TN. Phone: (901) 516-8162. E-mail: MurphyJ@methodisthealth.org.]