Healthcare Revenue Cycle Variability Impacts Payment Offerings

BALTIMORE — The portion of a healthcare bill that a patient is responsible for will increase significantly over the next few years as more companies move to high-deductible health care services. Because the probability of a patient paying the provider decreases significantly once the patient leaves the provider’s facility, providers must be able to give patients more payment options for outstanding medical fees and deductibles.

Before developing new payment offerings, financial institutions should consider and understand the healthcare revenue cycle, according to Brenda Fielder, EDI/EFT Product Manager, eServices for Health Care Professionals at Cigna, speaking at NACHA’s PAYMENTS 2012 annual conference.  The healthcare revenue cycle significantly varies from other industries. In developing new products or services, it is important to understand those differences and address them.

One of the biggest challenges providers face is giving patients an accurate estimate of fees owed, however.

According to Fielder, “The healthcare revenue cycle is complex because of the variables that affect fees and payment,” Fielder said. “Some payers return an estimate of how the claim would be processed and any patient responsibility amounts. On the other hand, some payers for limited services are able to process the claim in real-time and provide an immediate response regarding how much would be paid and patient responsibility amounts.”

Most payers require specific data elements be submitted on the claim for processing. For example, the patient’s ID number, diagnosis codes, date of service, and pre-certification authorization number, Fielder said. However, services including lab results, X-rays, and treatment plans require additional documentation and introduce new variables, adding another layer of complexity to the claim and payment workflow. 

Another opportunity to assist the provider is reducing the cost of accepting ACH claims reimbursement payments from the health plans and reconciling them to the Electronic Remittance Advice. 

“Help with reconciling accounts would go a long way toward increasing EFT adoption among healthcare providers,” Fielder said. For example, one of the biggest obstacles to adopting EFT payments is reconciling the healthcare EFT and ERA transactions, since the payment may not travel with the remittance.

To reassociate the remittance with the payment, the healthcare professional must match the information from the CCD+ record to the payment information on the Electronic Remittance Advice. The reassociation number is carried in the Payment Related Information field on the CCD+ addenda record.  The NACHA Operating Rules require financial institutions to provide this information to their Receivers upon request. 

Help with reconciling accounts would go a long way toward increasing EFT adoption among healthcare providers. Delivery of the Reassociation trace number to the provider by their financial institution is an important step in helping healthcare providers.


View the related PAYMENTS 2012 presentation.