By Amanda Eisel
Amanda Eisel has focused the last 20 years of her career at the intersection of healthcare and technology. She has been deeply involved creating and scaling multiple growth technology companies including Waystar, Applied Systems and Viewpoint. Amanda has been a member of the Zelis team since 2019, playing a leadership role across Zelis’ growth, operational and talent strategies. Amanda started her career at McKinsey & Company, where she spent nearly a decade advising consumer companies. Prior to Zelis, Amanda was an Operating Partner at Bain Capital focused on technology and healthcare IT companies.
What’s the hardest thing about riding a bike?Talking about it.
Unless you’re a cycling enthusiast, you probably can’t tell a sprocket from a Schrader and think a hammer is a tool used to drive in a nail. The healthcare financial experience, unfortunately, is similar. For many consumers, it feels like they need to be an expert in the field just to decipher their bill. In fact, 80% of consumers think their insurance plan needs a clearer process for dealing with billing errors.
Allow me to explain this by taking you on a brief journey. I want you to close your eyes, and imagine you had a bike accident. You’re getting a few miles in on the trail when all of a sudden, a big rock takes you by surprise. You fly off your bike, and next thing you know, you’re sitting in the emergency room with a torn ACL.
You need knee surgery and outpatient rehabilitation care, which is frustrating, of course. But it only gets worse from there when you begin to receive bills and a lot of paper that looks like a bill but says that it isn’t . After sifting through the trees of paper, you think you owe $16K for care.
Luckily, you’ve got great healthcare. You’re physically fine and will be back to riding your bike in no time, but your financial experience is just about as bad as the ACL tear. Newsflash, it didn’t go much better for your health plan or your healthcare providers.
With a traditional approach to the financial journey, we all suffer.
Consumers, payers, and providers alike are forced to deal with the complexity and inefficiency of opaque, fragmented, and paper-heavy processes.
Downshifting for the steep climb ahead
Like I just mentioned, the healthcare financial experience is extraordinarily complex. But it can be broken down into four main phases (or hills).
1. Accessing care.
Going back to our analogy above, let’s say you found your knee surgeon based on a recommendation from a biker friend who suffered the same injury a few years back. You then found your rehabilitation care based on the recommendation of the recommended surgeon.
Are alarm bells ringing in your head just yet? If not, they should be.
What you failed to realize while preparing for your surgery was that you were navigating across four different provider entities, and the rehabilitation provider was actually out-of-network with your plan.
Care decisions are not only crucial for the consumer but also for your payer and providers.
When you start the care journey in the dark about options available and cost of care, it greatly impacts how much you pay for care, if you ever pay what you owe, and how you feel about the care itself.
The CMS recently announced that ACA Marketplace enrollment is up 18% from last year. There are now more health insurance consumers going into 2023 than ever before. And we all know what that means: more consumers, more unique member needs.
As a payer, placing yourself in the role of the consumer allows you to create solutions that walk them through the entirety of the financial journey, leading to less abrasion and more smooth-sailing (or should I say “coasting”) further down the line.
2. Claim adjudication and pricing.
Your knee surgery and corresponding rehabilitation is considered a high-dollar episode of care, so your insurer flags it for review. Meaning: They do their own review and then send it to two external vendors for a line-by-line item review. Your claim is also sent to a third vendor to price your rehabilitation care (remember, it’s out-of-network, so it didn’t come with a price).
This creates a black box for your provider as to when and how much they will get paid.
3. Payment discrepancy.
After the review period, which is typically 30-90 days, the approved claim moves to being paid. So, yet again, we run into another patchwork of vendors.
Your providers aren’t in your payers’ electronic payment network, so the payment goes to a vendor to attempt payment via virtual cards. (For reference, those only get accepted about 50% of the time.) A portion of the payment moves to another vendor to cut paper checks and send the data corresponding to that payment in… wait for it… two separate envelopes via the mail to your providers.
Obviously, there then is a struggle to reconcile all of this, and, like always, a few disagree with what happened in the black box of claim adjudication, so they initiate an appeal.
4. Billing blasts.
While all of this is happening, the consumer (aka you) gets involved. The provider’s office sends you a bill. And this isn’t their first time riding a bike. (Yes, the idioms and puns are going to continue throughout this piece.)
They know that any bill not paid within 30 days of service is unlikely to ever be paid, so they start estimating what you’ll owe before they are settled with your payer. Meanwhile, you’re also receiving “this is not a bill” mail, explaining charges, discounts, and payments because your payer wants you to understand what they’ve done and plan to do.
None of these bills and non-bills match.
You call your provider and your insurer to make sense of it all, but neither can see the other’s systems, so they can’t help you, and you wind up more frustrated than you were before you picked up the phone.
This scenario plays out for months until someone gives up, leading to enormous financial waste, frustration, and lack of trust.
And since providers are now asking patients to pay in advance for services based on estimates, this process has only become more convoluted, as these payments often don’t take into account unprocessed claims from other providers.
According to a recent survey Zelis conducted in partnership with Hanover Research, only 30% of consumers feel extremely confident in their ability to identify an error in their medical bill, and almost half of respondents (43%) spent up to one month getting bills corrected.
The wrap up
At Zelis, our purpose is to modernize the healthcare financial experience for all – payers, providers and healthcare consumers. We can deliver significant value for our clients by collectively delivering a more transparent and actionable journey for consumers, one that isn’t riddled with confusion and frustration.
Consumers are increasingly engaged in their healthcare, talking to each other about the good, the bad, and the ugly, sharing referrals and their healthcare journey. Through our latest solution, Healthcare Intelligence, we normalize and translate the wealth of financial data from machine readable files (MRFs) into real, actionable insights that insurers can then use to provide tools, services and navigation needed to make the financial journey as seamless as possible for their members.
The fact is, while the Transparency in Coverage Rule requires payers to make MRFs publicly accessible, the files are large and written in machine language that isn’t easy for the average healthcare consumer like you or I to interpret and understand.
We need to fuel a better healthcare experience through price transparency, meaningful financial incentives, and open communication across the payer, provider, and consumer spectrum. And I like to think Zelis is empowering our clients to do just that.
To gain insight into this breakthrough new solution, please visit us here.