Director of Member Services and Innovation
What Is Surprise Billing?
Unfortunately, it’s a story we’ve all heard. A patient has double-checked their plan to ensure the doctor they’re seeing is an in-network provider and the associated bill will be paid by their health plan. Then, a few weeks later, they receive an unexpected charge on their bill because they unknowingly received services from an out-of-network provider at an in-network facility. Another situation may be when a patient receives non-preventative care when they were seeking preventative care.
In either case, the patient’s insurance company pays for a portion of the charge, but often less than the provider’s list price for the charge. The patient is then forced to foot the outstanding amount – what’s known as “balance billing” or surprise billing.
These surprise medical billings often amount to thousands, sometimes even hundreds of thousands of dollars.
Why Does Surprise Billing Happen?
Simply enough, the patient may not completely understand what’s considered as “preventative health” by their plan. This could happen when a patient goes in for a routine check-up, which is considered preventative, but inadvertently receives care their health plan considers as pre-existing treatment. For example, the physician finds an unusual lump on a patient during a routine exam, which is 100% covered, but orders further tests on the lump – which is classified as pre-existing treatment and isn’t covered.
In other instances, a patient may seek care from an in-network facility, but the provider happens to be out-of-network. Patients may choose their hospital, doctor, or even surgeon, for planned care, but the hospital may deem it necessary to coordinate with out-of-network ancillary providers – like anesthesiologists or radiologists – in order to properly care for the patient. This could leave the patient with a large surprise bill.
So What Can Employers Do?
Employers can avoid surprise billing altogether by ensuring they have a broad network of providers available to their employees. This ensures that employees have easy access to in-network providers and drastically reduces the need for out-of-network care. (The Alliance network includes more than 135 hospitals, 6,000 medical clinics, 13,000 medical doctors and 28,000 professional providers.)
Next, employers should invest the time to properly educate their employees about their benefits plan. If an employee doesn’t know the difference between an in-network provider and an out-of-network one, they are less likely to make a wise decision, especially in an emergency situation. The Alliance provides a plethora of provider navigation and educational resources that employers can use to help guide their employees to making cost-effective choices.
Lastly, employers can guide employees to use providers that offer bundled pricing for services. These pricing arrangements prohibit surprise billing from those services.
Your Employee Received a Surprise Bill – Now What?
If a patient receives a surprise bill, they should contact their TPA (Third-Party Administrator) to understand why a charge on their bill was not covered, and what their options are.
If they want to see a particular provider and are questioning whether that provider is in-network or out-of-network, they can contact The Alliance’s Customer Service by calling 800.223.4139.
Additionally, as an atypical effort to reduce the bill, patients can actually negotiate some charges, and a medical provider may reduce the cost of a bill if they agree to pay it in full.
If all else fails, they can file a formal appeal with the health plan. Instructions on how to dispute charges are usually located on the explanation of benefits from the TPA, but most require written notice and any documents you received from the provider.
Health care is confusing, but by utilizing a shared-site clinic to deliver advanced primary care, an organization can provide its employees with easy-to-access care while reducing their overall spend.
In fact, The Alliance advocates for this model so much so, that we are currently working with employers in multiple communities to establish our own shared-site clinics – available even to employers that are not members of The Alliance!
But first, let’s begin by defining the two clinic models and how each might benefit your organization.
Shared-Site and On-Site Clinics
Shared-Site Clinics are located at a community site and are available for use by employees and families from multiple employers. This is a popular option for smaller employers because costs are shared by all employers who are part of the clinic.
On-Site Clinics are located at a single employer’s worksite for use primarily by their employees only. This model provides employers with maximum control over the benefits their clinic offers.
How Are Clinics Funded and Staffed?
Some employers contract with a health care system when establishing a clinic. Why? It’s built, staffed, and subsidized by the health system. This allows an employer to provide their workforce with accessible health care with little effort and less financial risk.
Another way to access a clinic is by contracting with an independent vendor. This may require more up-front costs because the employer might be responsible for implementation costs. However, this model provides a greater long-term impact on an employer’s health care spend due to the independence it offers. Because the employer has more control over the clinic, they can use their claims data to focus on cost-saving measures specific to their industry or employee population. Additionally, any care that is referred outside of the clinic can go to the highest value provider, and is not restricted to a specific health care system.
What Are the Benefits?
One benefit of using a shared-site clinic is it can be a big time-saver for employees. Patients usually see their doctor more quickly (and more often) thanks to their clinic being in closer proximity to their workplace. This is a big deal because, according to research by The American Journal of Managed Care, patients spend approximately 37 minutes traveling to their provider, and another 87 minutes being there – all for just 5-8 minutes of face-to-face time with their primary physician. Removing this time barrier and guaranteeing next-day (or even same-day) appointments incentivizes patients to see their health care provider more often, who, in turn, spends more time with the patient because they serve a smaller patient population.
Perhaps a more obvious benefit to using one of these clinic models is that it often saves on total health care costs. For example, about six years ago Brakebush Brothers opened an on-site clinic. Today, their healthcare costs are less than what they were in 2014!
In traditional health care, the employer’s health care costs increase as their employees increase their health care utilization. Typically, the only tool employers know they have to offset those costs is to raise employee co-pays – which is a difficult decision to make. But with a clinic model, employers are paying a set fee for accessing the clinic, so employers aren’t burdened with higher costs for excessive health care utilization. Additionally, the use of urgent care and the emergency room decreases when patients have the convenience of a nearby clinic.
And last but not least, employers can reduce absenteeism, increase retention rates, and become an employer of choice in their area by providing cost-friendly, easy-to-access primary care in the form of an on-site, near-site, or shared-site clinic.
Interested in starting or joining a Shared-Site Clinic? Contact Member Services.
The traditional health care model can be hard to access, tough to navigate, and unnecessarily expensive. But there’s another way you can approach primary health care that makes your employees healthier and helps with your bottom line — advanced primary care.
Different, Better Care
When people’s health concerns are confined to rigid appointment times, often scheduled weeks in advance, and their doctor only sees them for 10 minutes at a time, it’s hard for patients to paint the whole picture about those concerns. In fact, 85% of doctors say they lack time during appointments to meet their patient’s needs. This shortage of time can cause doctors to over-test, which costs the patient more time and money, or they can misdiagnose or overprescribe, impacting the patient’s health.
On the other hand, with advanced primary care, patients enjoy more time with their care provider, see them more quickly, and may spend less time traveling to appointments.
When patients have the freedom to schedule appointments at flexible times and see their providers either in person or online, they are more likely to seek care at a clinic rather than urgent care or the emergency room.
Advanced primary care can handle most of the health care needed, but there are times when care does need to be referred outside of the clinic. In those cases, an advanced primary care provider will guide a patient to lower cost, higher quality options and stay connected with the patient throughout the outside appointment. This gives patients access to an advocate through the health care process versus being lost in the system on their own.
In this model, providers have more time and resources to provide better care, the patient receives more convenient care for less money, and the employer saves on their overall health care costs. Everybody wins.
The Four Best Benefits
There’s no shortage of perks for offering advanced primary care to your employees and their families, but here’s our top four:
1) Employers can see their overall cost of health care lower by as much as 15-30%, with savings beginning in as little as 12 months. (In 2014, Brakebush Brothers opened an on-site clinic. Today, their health care costs are less than what they were in 2014.)
2) Employers don’t need to make the hard choice of increasing cost-share to employees in order to control health care utilization. With employers paying for the cost of accessing the clinic, there are no concerns about over-utilization of the services. Also, the use of urgent care and the emergency room goes down when patients have the option of advanced primary care due to the ease of access and reduced costs.
3) Recruiting and retaining employees can be made easier by offering access to advanced primary care at no cost to employees.
4) Referrals to lower-cost, higher-value specialists and procedures extends the value of the advanced primary care, even for care that happens outside the clinic.
For more information on how we can help you offer this to your employees, contact the Member Services team.
With the new year comes new benefit plans. The Alliance wanted to provide some helpful tips on what can help employers, and employees, get off to a great start.
For employers that are new to working with The Alliance or those that would like a refresher on what we do, we would recommend contacting your Account Executive to cover the following topics.
What does it mean to be a cooperative?
Learn about your ownership in the company, as well as benefits like stocks and patronage checks.
What is the advantage to working with The Alliance?
We like to discuss our vision for health care and how our reference-based contracting can help you offer your employees and their families quality care at the right price. We also like to connect you with other like-minded employers in your area.
What kind of data intelligence can The Alliance provide?
At The Alliance, we provide employers with detailed reports on utilization, ROI, steerage to high-value health care, a breakdown of spend, and a review of appropriate ER usage to help control costs to name just a few.
If members are new to working with The Alliance, we may not have sufficient data to analyze. We can provide sample reports to give you a sense of what you can anticipate receiving in the future.
How does The Alliance help employers contain costs?
In addition to our network, we can also discuss advanced primary care and how we help employers offer these services to employees. One of the ways we accomplish advanced primary care is through onsite or shared-site primary care clinics. Employers can pay a monthly fee per employee instead of fees for each service that can help save costs for the employee and employer. And by offering longer appointment times, these clinics allow employees to get all their needs taken care of in one appointment. The Alliance can even work to connect employers in an area who may be interested in a shared-site clinic.
We can also can help steer employees to high quality, lower-cost providers and bundled services that offer more transparency in pricing and include the total cost for an episode of care.
What kind of services can The Alliance provide beyond a network and the cost containment strategies above?
We have your data, once you work with us, so we’re happy to customize our services to fit your needs. And we regularly take feedback from our members to develop new analytic capabilities and enhance our offerings.
Does The Alliance have any tips for employees?
Encourage them to navigate the provider directory to get familiar with how to use it before they need services. If they have questions, they can visit our Frequently Asked Questions page call us at 1-800-223-4139.
Introduce employees to our concierge service for pricing services. This can help them anticipate and budget for health care costs.
Remind your employees to show their new id card to providers to ensure proper billing.
And make sure they understand their benefit plan design and any incentive programs you have in place.
What if I’m new to self-funding?
There’s a lot to learn, and we’re happy to provide education around what that shift means and who does what. Here are some suggestions on who to call for what:
TPA: Billing Questions, like stop-loss, and helping employees with questions about how their claim is adjudicated and tracking deductible spend.
The Alliance: How to get a doctor in-network. If you find a doctor that isn’t in our network, we’re happy to negotiate on your behalf to get them in-network.
And don’t forget our events which offer great educational and networking opportunities! If you have any questions, please reach out to your Member Services team!
High-value care can help you pursue better outcomes for employees while reducing the total cost of care. So how do you tell if primary care is high value?
Self-funding your health benefit plan can be rewarding for employers. Yet experts say common pitfalls still undermine too many employers’ best efforts.