Embrace Regulations to Deliver the Best Patient Experience
By Howard Bright,Vice President Patient Engagement, RevSpring
The difference between stumbling blocks and stepping stones lies in how you use them. That bit of folk wisdom is an excellent way to approach new regulations as avenues for building patient relationships. Some hospitals will only see stumbling blocks: huge tasks that require checking another box. Others will embrace the price transparency regulation and No Surprises Act as valuable stepping stones, moving them closer to engaging patients and building their trust and loyalty.
It all begins with understanding the perspective of your patients. Patients have changed as the healthcare financial landscape has been shuffled during the past five years. They’re now paying for a larger portion of their healthcare bills, making patients the new payers.
Demographic shifts also are transforming patient expectations. The aging U.S. population means more digital natives are coming into the healthcare system. They expect quality information and engagement to be easily accessible anytime via their phones and other mobile devices. These patients are digital savvy consumers with high service expectations. Friction is simply not acceptable.
Regulations Today
Before delving more deeply into how providers can leverage patient expectations—and what the government requires—to build stronger patient engagement, let’s take a quick look at where things stand with new regulations today. The federal price transparency regulation went into effect on January 1, 2021. Its purpose: create competition in healthcare by letting consumers shop for providers and services based on prices.
The No Surprises Act, which prohibits balance billing by out-of-network providers in emergency and other specific situations, was enacted by Congress last December as part of the Consolidated Appropriations Act. It says that a health plan that provides emergency coverage must do so without prior authorization and with no regard to if the facility is in-network or out-of-network, and providers cannot balance bill patients for out-of-network emergency care. Providers also cannot balance bill for ancillary charges by out-of-network physicians at in-network facilities. For other charges by out-of-network physicians at in-network facilities, patients must explicitly agree to waive their protections against balance billing before being billed out-of-network rates (more on that in a minute).
“Requirements Related to Surprise Billing; Part I,” an Interim Final Rule (IFR) addressing the No Surprises Act
from HHS, the U.S. Departments of Labor and Treasury, and the Office of Personnel Management took effect on September 13 of this year, but most of its provisions don’t apply until January 1, 2022. The IFR addresses several provisions in the law, including:
- The ban on balance billing for emergency services and the requirement that cost sharing for emergency services be on an in-network basis.
- Method of calculation of patient cost sharing amounts (i.e., the Qualifying Payment Amount).
- The process for providers to give patients notice of, and patients to provide consent for, being billed outof- network charges.
- The basics of the complaint process to report violations.
“Requirements Related to Surprise Billing; Part II” was published on October 7, with a 60-day comment period that ends on December 6. This second IFR covers the following:
- The independent dispute resolution (IDR) process, which can be invoked when payers and providers can’t negotiate the payment rate in the 30-day negotiation window. It includes template forms and criteria to become an IDR entity that can settle disputes.
- Good faith estimate requirements. If a patient has no insurance and opts to pay out of pocket, then the provider must give a written, “good faith estimate” of the costs for the items and services.
- Patient/provider dispute resolution process for good faith estimates issued for uninsured patients.
- Expansion of scope of claims eligible for external review.
Letting Patients Know Builds Trust
Patient notifications are required within the No Surprises ruling, and that’s good news. A strong patient engagement strategy lets providers turn these notifications into sturdy stepping stones for building trust and standing apart from grudgingly compliant providers. Making it easy for patients to see, read and understand the information is an obvious place to begin.
The ruling allows for billing out-of-network rates in some cases but is quite explicit about advance public disclosures and patient consent. Disclosures must be easily accessible and readable on provider websites and in their facilities. Disclosures must be provided in-person, or via U.S. mail or email (according to each patient’s preference).
To make it easy, HHS has provided a model disclosure notice.1 Providers that not only follow these rules and the HHS model, but also go the extra mile to make information extra user friendly will gain an important advantage in competitive healthcare markets. The information even can become a patient satisfaction tool when handled well.
The price transparency regulation is another patient engagement opportunity in disguise. The price transparency regulation mandates providers publish pricing information in a consumer-friendly format—including payer-specific negotiated charges—on at least 300 shoppable services. Hospitals that publish payer-specific charges in plain language and easy-to-access formats will distinguish themselves as patient-friendly facilities.
Most hospitals are not currently in compliance, which means they are missing a golden opportunity to set themselves apart in a positive way. Technology exists to facilitate getting the pricing information organized and online in a streamlined and easily accessible way for patients. This will be noticed and appreciated amidst a sea of confusing or non-existent information at other hospitals.
Your Bottom Line
Government regulations will continue to change and evolve, but one thing will remain constant: creativity around price transparency and billing opens up many new avenues for patient engagement excellence. Shoppable service lists and interactive websites that mimic the retail experience—including service listings, personalized price estimates and appointment scheduling—are just two of today’s stepping stones toward a more engaged patient base tomorrow.
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