Hospital Price Transparency: Does it Change Your Outreach Lab Program Strategy?

Recently, I had the great privilege to participate in a Healthcare Financial Management Association (HFMA) virtual panel discussion on compliance with hospital price transparency requirements. One of the primary topics I covered during the discussion was how technology can help reduce the “lift” for hospital outreach laboratories to achieve and maintain compliance with the new rule, which became effective January 1, 2021.

First, a quick recap of the new rule. Its intent is to make it easier for consumers to shop for services and compare prices across hospitals as well as estimate the cost of care before selecting to schedule a service. Specifically, hospitals operating in the U.S. are now required to provide clear, accessible pricing information online about the items and services they provide in two ways:

• As a comprehensive, “machine-readable/searchable” file containing all items and services
• In a readily accessible display of shoppable services in a consumer-friendly format

To accomplish this, a patient responsibility estimation tool can be prominently displayed on the hospital website, offering patients access without charge and without having to register or establish a user account or password.

Perhaps not obvious, XiFin sees this price transparency rule as a net benefit for hospital outreach laboratories because it creates a real incentive for the upfront confirmation of the patient’s out-of-pocket expense. The rule brings with it the opportunity for providers to move that patient and payor information collection process upfront, and perhaps even collecting the patient portion of the expected bill earlier in the process. I believe that benefit probably outweighs any potential concern over loss of business caused by this new compliance requirement.

Regarding how much of a “lift” compliance is, I think it all comes down to technology. Without the right infrastructure, automation, and outreach-specific payor relations expertise, compliance is a heavy lift for the hospital. In addition, the hospital’s outreach programs may not be the highest on the hospital’s priority list for transparency compliance. This too impacts how significant the lift is for the outreach program.

For XiFin customers, this equates to a detailed fee schedule and the client, test, and payor-specific logic that drives workflow automation. Therefore, compliance for XiFin supported outreach programs shouldn’t be a heavy lift. That said, an internet-based patient estimation tool is no easy task. Selections need to be made for the right test, the right payor and the right payor plan to get an accurate estimate. Patient estimation therefore requires direct electronic connection to all of the payors to obtain eligibility, deductible and copay or coinsurance information in near real time. If outreach programs are using enterprise systems such as electronic health records for outreach claims processing – their ability to comply with the new requirements and deliver accurate patient out of pocket estimates may be more challenging. Purpose built outpatient RCM solutions work to interoperate and enhance EHRs.

Long before these requirements were issued, XiFin invested in patient and physician engagement tools that provide transparency, reduce the chance of surprise bills, and make patient payment collection easier and earlier in the process. These tools include:

• Client portal for ordering or referring physicians to look up test pricing at the time of the patient encounter.
• Patient responsibility estimator that provides real-time expected out-of-pocket expenses that consider eligibility co-pays, deductibles, etc., at the payor plan level across thousands of payors. This estimator is made available through a patient service center used at the lab, via the client portal where the physician can get the estimate for their patient, as well as through a patient portal that is accessible 24/7.
• The ability for labs to text or email patients with a link to view their estimate via the patient portal. The patient can then approve the test, once they know their expected out-of-pockets cost and can even pre-pay their portion.  

There are more than a dozen laboratory or pathology-related CPT codes that are considered “shoppable” services and another dozen for radiology, including services such as:

• Obstetric blood test panel
• Liver function blood test panel
• Kidney function panel test
• Prostate-specific antigen (PSA)
• Mammography
• Ultrasound of abdomen
• CT scans of brain, pelvis, or abdomen

It is more important than ever to have an accurate financial and competitive picture of your outreach lab. Detailed business intelligence at the test, client, and payor level will be imperative to negotiate or renegotiate payor contracts, manage referring provider profitability, understand the costs of tests provided, etc. Revenue cycle management and standard reports are no longer enough to understand costs and profit margin. Business intelligence with advanced analytics are required.

These new regulations and changing patient expectations require interoperable and ancillary service-specific technologies that enhance enterprise systems so pricing transparency is not only accessible but accurate across all ancillary services.

XiFin has more than 20 years’ experience partnering with hospital outreach programs, health system ambulatory services, imaging centers, independent laboratories, medical device organizations, pathology practices, and specialty physician groups to optimize billing and claim processing.

We offer unrivaled flexibility to meet your needs, whether you manage the billing yourself, outsource to our internal operations, or need a hybrid of both. Our unique model can help design a solution that fits today while providing the flexibility to adapt to your changing needs.

Contact us to find out how you can potentially outsource all or part of your RCM process in as little as 30 days.

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