New year, new name! We are proud to welcome you to the future of healthcare revenue cycle management – welcome to Meduit! Please allow us to reintroduce ourselves.

What is Meduit?

Our team is now comprised of today’s top RCM companies – MedA/Rx and Receivables Management Partners (RMP) – which work together to leverage their unique strengths across the entire revenue cycle. With Meduit at the center we have collaborated to bring our expertise together across functions, including technology integration, deeper data analytics, and cross-product offerings.

Why bring these two national RCM companies together now? Current challenges and changes in the healthcare revenue cycle space have created a need for dynamic solutions – the kind that can only come from experience. Patient volumes are increasing and shifting from inpatient to outpatient services, and patient expenses have increased 10-fold with healthcare reform. These changes are resulting in razor thin margins for providers and are taxing already tight resources for effectively working AR. That is where Meduit comes in.

By delivering expert, efficient, and innovative RCM solutions, Meduit significantly improves financial and operational performance. We turn AR into cash faster, and operate as a trusted partner and true extension of our clients’ business offices. We accomplish this through our robust methodology and model, backed by leading-edge technology, and fueled by a compassionate team with a drive to do the most good for more people.

The Innovation Lab

Now that you know a little more about who we have become, let’s talk a bit about the brand new Meduit Innovation Lab. We are driven to contribute to the effectiveness, stability and accessibility of healthcare services for patients by ensuring outstanding AR management that leads to maximum financial performance for healthcare providers. So we want to share what we know about how to improve your revenue cycle, and we are going to do that by delivering training resources and industry updates right to your inbox.

For our former RMP Insights subscribers and readers, not much is going to change. Although you can expect even better information thanks to our expanded team of RCM experts. We will be sharing tips from our team of subject-matter experts and consistently fresh training and educational materials (we’re talking reference guides, slide decks, eBooks, webinars, training videos and more!). In fact, we already have a full library of resources ready for you to explore here. Additionally, every other week we will be blogging about all the aspects of your business and industry that could be affecting your receivables, from ever-changing compliance regulations to emerging technology trends, with tips on how to improve every step along the way while maintaining the critical relationships you have developed with your patients. (By the way, there are already several articles published for you to explore here.) Oh, and did we mention it’s all free?

If we have you convinced, be sure to join the Meduit Innovation Lab and start improving your revenue cycle today, one email at a time.

Enough About Us

We want to learn more about you! What challenges are you facing? Which aspects of your revenue cycle could use a boost? What training resources could benefit your back-office staff? Each post will include a comments form, and every email can be responded to (yes, they come from a real person!) so please do not hesitate to submit your questions or feedback.

We are thrilled to bring you along with us on this journey into the future of revenue cycle management. Welcome to Meduit!

Written by Ali Bechtel, Marketing Manager, Meduit

This information is not intended to be legal advice and may not be used as legal advice.  Legal advice must be tailored to the specific circumstances of each case.  Every effort has been made to assure this information is up-to-date as of the date of publication. It is not intended to be a full and exhaustive explanation of the law in any area, nor should it be used to replace the advice of your own legal counsel. 

Calling patients to request payment can be stressful and difficult, but it doesn’t have to be. Like every other touch point you have with a patient, the first and most important requirement for a successful patient collection call is to create a connection. If you approach a financial call with the same attitude as a registration or follow-up call you will set a positive tone for the conversation, and that can go a long way.

But that may be easier said than done when you are met with objections, excuses, or a refusal to pay. So we have also identified 8 easy to follow steps to get you through every call successfully:

1. Identify the Patient

The very first step of every call is to identify that you have the correct patient on the line. This step serves two very important purposes: preventing a HIPAA violation by providing PHI to the wrong party, and establishing a feeling for the call. Start by asking the right question:

“Hello, may I please speak with John Smith?” This is not the right question. Anyone familiar with John, and who he may want to talk to, won’t ask for him this way. This introduction is going to lead him to assume that this is a call he doesn’t want to answer, and so “John isn’t available at the moment.”

“Hi, John?…Hello Mr. Smith…” A simple greeting like “Hi, John?” will make him much more comfortable and more likely to continue the conversation. After he confirms his name, follow-up with his last name to ensure that you have the right person on the phone.

2. Identify Yourself & Your Employer

Once you have identified the patient, let them know where you are calling from. Remember: patients often will not recognize the corporate name for your healthcare organization, but they will remember their doctor’s name. It is important for the patient to recognize where the call is coming from right away. If they don’t know who you are and you start asking for money there is a good chance they will become defensive or confused, which is not likely to lead to payment. Try this:

“Hello, John?”

“Yes?”

“Hi Mr. Smith, this is Mary calling from Dr. Jones’ office at Respiratory Specialists. How are you today?”

3. Request Payment in Full and Offer Methods of Payment

Yes, you want to ask this question right away. Respect their time and get right to the point of your call, especially if they are impatient or indicate they are in a hurry. This part can be difficult, so use your judgment. Review their history to determine whether it might be better to lead into the request by following up on their latest appointment, confirming their demographic information, or asking for any secondary insurance before requesting the balance.

When you are ready to ask for payment, request the balance in full 100% of the time. Often you will not get it, but if you do you have just saved yourself four steps, and you can skip to step 8.

Asking how much they can “put toward” their balance indicates that they are not required to make a full payment. Instead, try asking: “How short of the balance are you today?” This question forces them to think about their entire balance and work down to what they can pay, rather than starting from zero and trying to work them up to an acceptable amount.

4. Psychological Pause

Once you have requested payment in full, give the patient a chance to respond. It is tempting to fill the awkward silence that follows such a request, but you need to give them a chance to agree to pay, or to offer their objection. It is easier to work with a patient when their objection is clear, so it is critical to allow them to give it.

5. Determine the Problem

This can be the hardest part. If the problem is simply that they cannot afford the total amount you know you need to attempt to arrange a payment plan. However, if they offer an objection or excuse for why they should not have to pay the bill, it is now your responsibility to determine the real root of the problem.

Objections about their care or their appointment that didn’t come up right at the time of service often mask other underlying issues, like confusion about their bill or their coverage. Working to the core of the issue and answering any questions the patient has will help them take responsibility for the bill.

6. Find the Solution

Once you have determined the real issue behind the patient’s inability or unwillingness to pay, work with them to establish a payment arrangement that addresses that problem. Make sure the arrangement is mutually agreeable; it should suit the patient but also be acceptable under your practice’s financial policy.

7. Close the Arrangement

Once a payment plan has been arranged confirm all the details with the patient, including the implications of failure to comply. Discuss the steps that will be taken in the event of nonpayment as they are outlined in your practice’s financial policy. Be sure to specifically provide all time limits and to fully explain any caveats or restrictions.

8. Update your Records

You made it! You’ve helped the patient to take responsibility for their bill, and secured payment or made an acceptable arrangement. All that is left is to record the details, including any reasons given by the patient regarding their inability to pay. These objections may come back up in the future and having detailed notes can help with future conversations.

Payment plans are only successful when they are enforced, so if your charge capture system has the ability, set a notification for the dates on which payments are due to ensure that the patient is adhering to the arrangement.

Putting these steps in place can help increase revenue while maintaining a good relationship with your patients. Collecting money does not have to be difficult, and the call can create an opportunity to connect. Taking the time to understand the patient’s situation and showing a willingness to work with them will improve their experience with your healthcare organization and will keep them coming back.

Want more tips for improving self-pay or self-pay after insurance balances? Download our free Patient Collections 101 Webinar on Demand!

Take this article with you! Click here for a printable version.

Written by Ali Bechtel, Digital Marketing Manager for RMP

This information is not intended to be legal advice and may not be used as legal advice.  Legal advice must be tailored to the specific circumstances of each case.  Every effort has been made to assure this information is up-to-date as of the date of publication. It is not intended to be a full and exhaustive explanation of the law in any area, nor should it be used to replace

the advice of your own legal counsel. 

Reform is rampant in the healthcare industry, from payment models to data security it seems there is always a new overhaul underway. But unlike many trends, patient engagement has remained a hot topic for many years. It is no secret that providing a great patient experience can improve your bottom line, so what is different about this trend that has kept it in the spotlight?

Engagement Directly Affects Revenue

Patient engagement initiatives are no longer about simply providing a good experience. That has become an expectation. Now efforts should be focused on patient activation – or the patient’s understanding and ownership of their own role in the care process. Most payment models, from government to private payers, are determining reimbursement based on the positive outcomes that result from activation.

However, payer reimbursement is not the only revenue stream influenced by patient engagement. Obviously, the patient experience is also going to directly affect patient payments. With patients now responsible for more than 30% of some organizations’ receivables, focus on providing an exceptional experience is at the forefront of many practice strategies.

As with any other service, patients are now shopping for the best deal, and the best experience. If they are not happy with the service provided by your practice, they will go somewhere else. If your practice wants to maintain its clientele, it is important to leave behind your payer-centric or provider-centric approach for one that is more patient-centric.

Consumerism Has Reached Healthcare

Healthcare organizations are now in the practice of working with consumers formerly known as patients. The healthcare industry has seen a rise in consumerism as a result of rising out-of-pocket costs. As patients become responsible for more of the cost of care they are beginning to shop for services based on cost, experience, reviews, convenience, and a whole host of other factors that previously did not influence healthcare decisions.

When faced with several thousand-dollar deductibles and a higher share in the costs after that is met, patients are demanding more financial transparency, typically by asking for estimates prior to services being rendered. These estimates are influencing whether and where they will receive care.

In order to improve patient engagement your practice should invest in tools to streamline the research needed to determine patient responsibility and to provide more accurate estimates. Providing financial support throughout the entire revenue cycle can improve their experience and keep them coming back.

Who is Responsible for Patient Engagement?

We know patient engagement is important, but who in your healthcare organization should be held responsible for ensuring an exceptional experience? The primary answer is everyone. An episode of care begins as soon as the patient schedules their appointment and continues all the way through their final bill, and every touch point along the way is an opportunity to encourage activation. But there is one particular team who bears a larger burden.

While it may seem like the provider has the largest impact on engagement, that is not the case. We know that first and last impressions are the most important and easiest recalled in any interaction. The patient’s first experiences are with patient access, registration, and check-in and their last are billing and payment. So their experience of the entire episode of care begins and ends with your revenue cycle staff. Consider this when you are implementing new engagement strategies to be sure you are focusing your efforts in the right place.

5 Goals to Set for Improvement

Whether you are implementing a new engagement strategy or overhauling an existing one to keep up with the shift toward activation, there are five goals to set within each stage of the revenue cycle:

1. Build relationships
2. Drive loyalty and adoption
3. Improve response rates
4. Reduce time to cash
5. Minimize the cost to collect

The first goal for every member of your staff should be to develop a good relationship with the patient. Developing a connection and providing an excellent experience every time will drive customer loyalty and foster the adoption of the engagement tools and processes you put in place.

Adoption of these tools – such as online scheduling and bill pay or completing satisfaction surveys – will lead to improved response rates and outcomes. This in turn will reduce time to cash for patient payments and boost reimbursement from your payers while also minimizing the cost of collections. If you succeed at the first two goals, the rest will follow!

Want a step-by-step guide to creating a successful patient engagement and activation strategy? Download our free Creating Connections eBook!

Take this article with you! Click here for a printable version.

Written by Ali Bechtel, Digital Marketing Manager for RMP

This information is not intended to be legal advice and may not be used as legal advice.  Legal advice must be tailored to the specific circumstances of each case.  Every effort has been made to assure this information is up-to-date as of the date of publication. It is not intended to be a full and exhaustive explanation of the law in any area, nor should it be used to replace the advice of your own legal counsel. 

Your receivables management partner should be monitoring and adapting to the ever-changing regulations in both the health care and debt collection industries on your behalf. However, there are a few reporting best practices you should follow to ensure that your agency, and your practice, can maintain compliance. In this article we will discuss the most important information you should be sharing with your medical collection agency or RCM partner on a regular basis.

Updated Patient Information

The Fair Credit Reporting Act (FCRA) and Fair Debt Collection Practices Act (FDCPA) have strict regulations in place for protecting patients from unfair collection practices. One of these regulations requires the timely reporting and updating of patient information, especially when a derogatory mark is being placed on their credit report.

The three major national credit bureaus – Experian, Equifax, and TransUnion – are now requiring at least a date of birth and/or a social security number as a unique identifier for every patient account being reported to ensure the wrong person is not being affected. It is critical that your agency has the most current demographic information for each of your patients. This is not only important if your practice credit reports, it will also ensure they are following up on the proper patient accounts and can help avoid HIPAA and Telephone Consumer Protection Act (TCPA) violations.

Payments

It is not uncommon for a patient who has been contacted by a debt collector about their bill to reach out to your practice or hospital to settle their balance. To ensure your agency is attempting to collect the right amount, they must have the most up to date balance on all accounts. This is particularly important if your agency credit reports. New credit scoring models and initiatives remove paid accounts from consumer credit reports, and if payments are not promptly posted and subsequently removed it could result in a dispute.

Even if your practice does not credit report, failure to report payments to your agency can still result in improper billing, which could certainly affect patient satisfaction and their relationship with your practice.

 Credit Disputes

The FCRA also requires data furnishers to conduct an in-depth investigation of all credit report disputes within thirty (30) days. This review must include any supplemental information provided by the bureau as well as all information provided to your office by the patient since the date of service in question.

In order to comply with this mandate, it is essential to develop a policy for communication with your agency in the event of a dispute to ensure investigations are conducted thoroughly and in a timely manner. An open channel of communication and proper documentation sharing will also result in the timely removal of any inaccurate or incomplete data furnished to the bureaus.

For your agency to be able to assist in these investigations, your practice must provide all available information within the allotted time frames to ensure the investigation is completed properly.

Bankruptcy Notices

When a patient files for bankruptcy an automatic stay is immediately placed on all creditors. This stay bars all collection efforts against the patient until the case is resolved. Any collection activity by your practice or your agency can be considered a violation of the court order.

Your agency should scrub accounts for bankruptcies before beginning any collection efforts, but it is still important to provide them with any notices you receive. Doing so will ensure they are not improperly reaching out to a protected patient.

Past-Due Accounts

One of the most important reporting tips we want to share is not about compliance, but about recovery. The cost to collect a past-due balance only increases as accounts age. Best practices suggest that you should be sending accounts to your agency no later than 120 days after delinquency, so long as that is line with your practice’s financial policy. Regardless of the age you choose, your practice should decide when to send collection accounts to your agency, share that timeline with patients in your financial policy, and strictly adhere to it.

In addition to collecting more of your past-due balances, agencies will also typically charge a smaller fee on younger accounts. Consistent reporting to your collection agency will help to improve their recovery and lower your costs for a much healthier revenue cycle.

Establishing solid lines of communication and policies for reporting any activity on accounts that have been sent to bad debt can help to ensure that both you, and your agency on your behalf, are in compliance with these strict federal regulations. Proper reporting will also ensure the smoothest account handling and can help to maintain the relationship that you have built with your patient by avoiding errors and disputes.

For a free downloadable guide of these best practices, click the button below:

Take this article with you! Click here for a printable version. 

Written by Ali Bechtel, Digital Marketing Manager for RMP

This information is not intended to be legal advice and may not be used as legal advice.  Legal advice must be tailored to the specific circumstances of each case.  Every effort has been made to assure this information is up-to-date as of the date of publication. It is not intended to be a full and exhaustive explanation of the law in any area, nor should it be used to replace the advice of your own legal counsel. 

Healthcare business process outsourcing (BPO) used to be a strategy for cutting costs. Then for a time the BPO growth trend slowed as more organizations underwent mergers and acquisitions. Newly formed parent systems began to build Central Billing Offices to bring revenue cycle tasks back in house and to streamline their vendor relations.

However, the new reality is a need to balance the overwhelming need to keep up with a rapidly changing industry with growing patient expectations. Growing challenges, restrictions and mandates across the healthcare landscape are driving more and more systems to consider healthcare revenue cycle business process outsourcing services.

What Changed?

The implementation of the Affordable Care Act created an influx of new patients with insurance coverage and increased the size of aging populations, and as a result medical office staff and payers alike struggled to keep up with the boost in complex claims. The implementation of ICD-10 placed even more strain on already understaffed reimbursement departments, and the shift toward value-based healthcare left hospital staffs working harder than ever to comply with conflicting mandates for improved quality and reduced costs. These challenges were amplified by outdated systems that were unable to meet the expectations of an internet-driven world. Now the new administration has different ideas of how healthcare (and reimbursement) should be delivered, and these already limited resources will be stretched even further.

As a result, the revenue cycle management outsourcing market is projected to reached nearly $277 billion by 2021, up from $170 billion in just five years from 2016. Still, the decision to outsource revenue cycle tasks can be a difficult one. Review these five common industry trends that are putting pressure on hospitals and medical practices. If any of these are creating issues within your organization, it may be time to consider seeking outside assistance.

Reimbursement Delays

With new value-based payment models emerging almost annually, and new codes and procedures for requesting reimbursement from payers, it takes longer than ever to receive payment for services rendered. Coupled with the increased number of claims submitted since the implementation of the Affordable Care Act and payers beginning to withdraw from the marketplace, medical offices consistently receive inadequate reimbursements.

Your current in-office staff may not have the experience, or the time, to keep up with that growing pile of claims. Instead of your medical office staff taking time away from patients daily to process endless reimbursement paperwork, consider outsourcing the task. Your payments will grow and your staff will get time back to focus on what really matters – providing quality patient care.

Regulation Changes

It is no secret that keeping up with regulation changes is a full-time job. Not only must you keep up with healthcare-specific regulations surrounding the security of patient information, maintenance of tax-exempt status and the delivery of care, there are also updates that span multiple industries, such as the Telephone Consumer Protection Act and the National Consumer Assistance Plan, that may affect business processes (and ultimately revenue) as well. Understanding the ever-changing landscape and implementing protocols in a timely manner requires specialists that can dedicate the time to ensuring your compliance.

Staffing Shortages

Hospitals across the country are experiencing staffing shortages on every level. Understaffing can drive up costs and negatively affect the health and happiness of existing team members. More significantly, it can threaten patient satisfaction and safety. Make the best use of your medical staff and leave time-consuming back-office tasks to a team of professionals better equipped to handle them.

Technical Innovations

Technology changes almost as quickly as compliance requirements do. BPO providers can offer newer technology to assist in optimizing your revenue cycle that may be too costly or time consuming to implement on your own. Keeping up with the latest innovations can improve data security, customer service, and receivables.

Changing Patient Expectations

Patients are more informed about their health, and the cost to maintain it, than ever before. With the rise in patient responsibility on marketplace and high deductible health plans, patients are taking care into their own hands and shopping for the best experience for their dollar. Access to providers is essential to patient satisfaction, but that access suffers when providers are losing time with their patients to attend to endless stacks of paperwork and tasking.

For a complete guide to improving patient engagement, download our Creating Connections eBook!

Is BPO Right for You?

Medical customer service, payer reimbursement follow up and denial management, and early self-pay follow up are all tasks that are critical to the financial success of any healthcare organization. Yet of each these take up valuable time for busy physicians and staff – time they should be spending on providing an excellent patient experience.

The right healthcare BPO partner can strategize and scale solutions to meet your specific needs and provide services throughout the entire revenue cycle to help you elevate both the patient experience and your bottom line. Get a handy checklist for vetting potential partners from Becker’s Hospital Review here. The shifting focus toward improving quality and reducing costs is expected to lead to an even higher rate of adoption for these services.

It’s time to reassess your strategy to include an alternative delivery service for core revenue cycle management functions and processes. To learn more about how healthcare business process outsourcing can benefit your hospital or health system, contact us today.

Take this article with you! Click here for a printable version.

Written by Ali Bechtel, Digital Marketing Manager for RMP

This information is not intended to be legal advice and may not be used as legal advice.  Legal advice must be tailored to the specific circumstances of each case.  Every effort has been made to assure this information is up-to-date as of the date of publication. It is not intended to be a full and exhaustive explanation of the law in any area, nor should it be used to replace the advice of your own legal counsel. 

Price transparency is a critical element for ensuring not only a healthy revenue cycle, but also patient engagement and overall organizational success. With the spread of consumerism in healthcare, more patients are expecting pre-service estimates and a seamless billing and payment process. However there is one primary factor in that process that can be less than clear: insurance coverage.

As patients demand more information, particularly when it comes to financial responsibility, your front desk staff is going to have to answer more questions about benefits, eligibility, EOBs and coverage than ever before. While many medical office staff members have some training in this area, not all do.

In order to provide the best possible patient experience every person in your practice should have at least a basic understanding of the various types of insurance available, common terms, and what patients may be responsible for. After all, if they cannot explain to your patient why they owe money, the patient won’t be very motivated to pay it.

In this article we will overview the various types of responsibility and insurance plans your patients may have. We have also compiled a glossary of common terms. Get the printable list here.

Patient Responsibility

Each of these costs is part of the benefit package chosen by the patient, and is part of the agreement they entered into their carrier. It is important to remember that whether the patient is responsible for these costs, and for how much, will vary by plan.

Premium

The premium is the amount that must be paid for a health insurance plan. This could be paid entirely by the patient, by their employer, or the costs may be shared. Premiums are typically paid monthly, quarterly, or yearly. If the patient’s employer provides insurance and contributes to the premium, the patient’s portion of this responsibility is typically taken directly from their paycheck.

Deductible

The deductible is the amount owed by the patient for services before their plan begins to pay. For example, a patient with a $2,000 deductible will have to pay for all costs out-of-pocket until they reach $2,000, after which their plan will pay the majority (but usually not all) of their expenses for the remainder of their plan period. The deductible is renewed each year.

Some plans may pay for certain services before the patient has met their deductible, but that coverage varies by plan. Others may also incorporate a copay for certain services that can apply before the full deductible is met.

Deductibles have been getting a lot of attention lately as High Deductible Health Plans (HDHPs) become more commonplace due to rising costs. Most insurance plans that have high deductibles have lower premiums. It is very important to know whether a patient has met their deductible before providing services so that you can prepare them for the responsibility of up to 100% of the cost of the services you will be providing.

Coinsurance

Under most plans, patients are still responsible for sharing in the cost of care after they have met their deductible. The patient’s share of the cost, calculated as a percentage of the allowable amount, is their coinsurance. For example, if the coinsurance is 20% and the plan’s allowed amount for an office visit is $100, once the patient has met their deductible they are still be responsible for paying $20 for the office visit, and the plan will pay the rest. (Prior to meeting their deductible they would be responsible for the entire $100.)

Copayment

A copay is a fixed amount owed for a healthcare service, usually due at the time of service. It is technically a form of coinsurance but is defined differently, and must be paid before any policy benefits are payable by an insurance company. The amount can vary by provider and service, and can also be required for having a prescription filled.

Collecting copays from every patient at the time of service is not only critical to a practice’s financial success, it also affects reimbursement by insurance. To learn more about improving time of service collections, get our free Collecting from Patients eBook.

Maximum Benefits (or Capitation)

Insurance plans typically set a maximum amount they will pay in a plan year, known as maximum benefits or capitation. Once a patient reaches maximum benefits the insurance company will no longer pay for care, and the patient is responsible for 100% of the costs until their plan renews. Maximum benefits can be across coverage or for specific services. For example, a plan may have a maximum benefit of $6,000 for infertility treatments, and after reaching that limit the patient is responsible for costs associated with that care, while their plan may continue to cover other services for the remainder of the year.

Insurance Plans

What costs the patient is responsible for will vary based on plan type, as well as on an individual basis within each plan. While there is no formula for each and every patient will have to pay, being able to recognize the broad categories can help you determine what the patient may be responsible for, and can give cues for what to look for when running a verification and eligibility check pre-service. With so many to keep track of, we’ve made you a handy comparison guide.

Commercial Insurance

One of the most common forms of insurance is commercial, or private payer plans. These plans include major medical coverage, qualified health plans, and catastrophic plans as well as non-major medical coverage such as short-term and gap insurance. Commercial policies can be sold individually or as part of a group plan and are categorized according to renewal provisions and benefits provided. Patients coming to your office may have any one of these, or a combination of them.  With various narrow networks within these different plans, it is critical to confirm that your provider is in-network before providing care.

Major Medical Plan Alphabet Soup

Under the Affordable Care Act (ACA), all medical plans must offer minimum essential coverage; certain services and treatments must be offered on all plans regardless of the carrier. However, there are several coverage formats available based on the patient’s lifestyle and health needs.

Health Maintenance Organization (HMO) Plans: Under these plans an entire network of providers agrees to offer its services, and a primary care provider coordinates all services and care. This is one of the most popular options and is best for patients who regularly visit their family physician, but they do come with the least freedom to choose providers. These plans typically require patients to pay a monthly premium, an annual deductible, and copays or coinsurance for each type of care.

Preferred Provider Organization (PPO) Plans: Under PPOs patients can generally see any provider in their network, including specialists, without a referral. Care is coordinated by the individual rather than a PCP. People who regularly visit specialists often prefer this type of insurance. These plans typically require patients to pay a monthly premium, an annual deductible, and copays or coinsurance for each type of care, as well as higher costs for out-of-network providers and sometimes higher allowable amounts.

Point of Service (POS) Plans: POS plans are a hybrid of HMOs and PPOs, so patients are required to coordinate care through a PCP, but also have the option to visit out-of-network providers if they choose, but will pay out-of-pocket to do so. These plans are a little more versatile but a little more costly, and are best for those patients who require a little more flexibility in their care. They typically require patients to pay a monthly premium, an annual deductible, and copays or coinsurance for each type of care; coinsurances and copays are higher for out-of-network providers.

High Deductible Health (HDHP) Plans: This format is quickly becoming one of the most common as costs continue to rise. These plans require patients to meet a high deductible, sometimes thousands of dollars, before any coverage takes effect. These plans are often coupled with health savings accounts (HSAs) and are the best option for people who want to save money and don’t plan to use their coverage much. These plans typically have a lower monthly premium as well as copays and coinsurance.  Participants are encouraged to review their benefits carefully to learn what they will be responsible for before seeking care.

Non-Major Medical/Gap Plans

Short-Term Plans: For patients who miss open enrollment and need to start coverage mid-plan period, a short-term plan can hold them over with limited benefits as a safeguard against illness or accidents. This limited coverage does not meet the ACAs minimum essential coverage requirements, so they may come with a tax penalty and carriers may refuse coverage based on pre-existing conditions. These plans can provide coverage for any length of time from 30 days to 12 months and are nonrenewable.

Catastrophic Insurance Plans: These plans are designed to provide an emergency safety net for unexpected costs. They can stand alone or be coupled with another major medical plan in case of serious health issues. Similar to short-term plans, alone they do not meet the ACA’s standards and come with the same penalties and limitations.

Ancillary Dental and Vision Plans: Most major medical plans do not cover routine dental or vision care, and some patients or employers opt for additional coverage for these types of care. There are a wide array of options within these plans from discounted costs to full coverage.

Marketplace Insurance

The implementation of the ACA created the Health Insurance Exchange, or marketplace, where people without coverage can shop online for various types of insurance plans that meet the stringent requirements set forth by the Act. Each major medical format is available on the marketplace and is organized by “metal” category. These categories are based on how the patient and the plan share the costs of care.

Bronze: These plans generally have the lowest premiums and the highest deductibles and out-of-pocket costs. The insurance company pays 60% and the patient pays 40% in this category.

Silver: Patients who qualify for cost-sharing reductions based on their income may be able to select a silver plan, which has a lower premium as well as lower deductible and out-of-pocket costs. In this category the insurance company pays 70% and the patient pays 30%.

Gold: As the categories grow, the costs shift to higher premiums with lower deductibles, with more coverage provided by the insurance company and less patient responsibility. The insurance company pays 80% and the patient pays 20% in this category. Gold and platinum plans are less common due to their high monthly premiums.

Platinum: These have the highest premiums but the lowest deductibles. In this category the insurance company pays 90% and the patient pays 10%.

Government Insurance

In additional to commercial plans, there are also forms of government-assisted coverage. These services include Medicare, Medicaid, and Veteran’s Health Care.

Medicare Medicare is the federal health insurance program for people who are 65 or older (and is available to others in some cases) and is broken down into several parts. Coverage is based on federal and state laws, national coverage decisions by Medicare, and local decisions made by companies in each state that process claims for Medicare. Patients may have a single part or a combination, and determining what level of coverage they have is key to understanding their eligibility and benefits.

Part A: Hospital insurance that covers inpatient hospital stays, care in skilled nursing facilities, hospice and some home health care. Many people are eligible for premium-free Part A coverage, but in most cases those who have Part A also have Part B coverage and pay a monthly premium for both.

Part B: Medical insurance coverage for certain medically necessary services, outpatient care, medical supplies and preventative care. Patients pay monthly premiums for this coverage, but if they are receiving Social Security or other retirement payments the premium may be automatically deducted from their benefit payments. The current standard premium amount is $134.00 per month, but may be higher based on income.

Part C: Also known as Medicare Advantage Plans, these plans are offered by private companies that contract with Medicare to provide Part A and B benefits.

Part D: Adds prescription drug coverage from private insurance companies approved by Medicare to Original Medicare.

Medicaid A joint federal and state program that helps with medical costs for people with limited income and resources. Each state has different eligibility and patient responsibility requirements, and some people are eligible for both Medicare and Medicare. These “dual eligibles” often have most of their care covered, and there are specific processes for submitting claims to Medicare first, then to Medicaid, for reimbursement.

Veteran’s Health Administration The VHA is America’s largest integrated health care system and provides coverage to people who have served in active military service or are current or former members of the Reserves or National Guard who were called to active duty. Eligible veterans typically receive treatment at one of the 1,245 participating healthcare facilities nationwide, including 170 VA Medical Centers, but some care may be referred to private providers if the VA cannot provide the necessary care.

With so many plan types it can be hard to keep them all straight, so we’ve made you a handy comparison guide. Get it, the common terms glossary, and printable version of this article by clicking the button below!

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Written by Ali Bechtel, Digital Marketing Manager for RMP

This information is not intended to be legal advice and may not be used as legal advice.  Legal advice must be tailored to the specific circumstances of each case.  Every effort has been made to assure this information is up-to-date as of the date of publication. It is not intended to be a full and exhaustive explanation of the law in any area, nor should it be used to replace the advice of your own legal counsel. 

In healthcare, as it is in many industries, cash is king. Of course your financial team will deep dive into financial performance throughout the year, but on a regular basis many hospitals and practices assess the health of their revenue cycle based on cash flow alone. Continue Reading Get a Revenue Cycle Check Up: Measurements for Success

In light of evolving threats – like the recent WannaCry ransomware outbreak – the data security industry is seeing a shift in approach from traditional signature-based tools to more behavioral analytics. This is a particularly important trend for the healthcare industry to follow given the targeted attacks many systems across the country, and throughout the world, have experienced in recent years.

Security Threats That Make You WannaCry

On Friday, March 12 the world experienced a well-coordinated ransomware attack, known as WannaCry that infected systems on a larger scale than has ever been seen before. Ransomware, and more specifically crypto ransomware, is a virus designed to search for a certain predefined set of file extensions that are typically used with protected data on a network. It encrypts, or locks it, requiring the owner to pay a ransom for a decryption key. This seems to be the preferred tool for attacking healthcare institutions; with lives on the line organizations are forced to pay the ransom quickly to gain access to patient information critical to providing proper care.

More than 150 countries and 200,000 systems were infected by the WannaCry attack across businesses, universities, and yes, health systems. The U.K.’s National Health Service (NHS) was the first identified victim, and was the day’s most severe hack. A total of 48 NHS organizations were hit, rendering patient records unavailable and forcing it to suspend operations.

Outsmarting Tradition

As viruses become “smarter,” – capable of seeking out the most sensitive information on a network to encrypt – our data security efforts must exceed their pace.

Traditional antivirus protection is signature-based. Like a vaccine it uses the signatures of previously identified viruses to detect new incoming threats. The software is updated for each new virus or malware signature detected, but it cannot keep pace with rapidly mutating ransomware strains. Ransomware signatures multiply quickly as hackers put their own spin on existing strains, and by the time your traditional antivirus protection is updated for the most recent one, a new mutation could already be hitting your inbox.

Next Gen Antivirus

The future of data security is in behavioral analytics-based protection. Just as viruses are learning to identify sensitive information, behavioral-based tools are learning how to identify ever-mutating virus signatures. These tools are more like a broad spectrum antibiotic; they look for the behavioral cues of a virus rather than a specific signature. Many even have the ability to sever a connection before any damage can be done. Essentially, rather than searching for the signature of a virus that encrypted something yesterday or last week, it searches for a signature that looks like it might be able to encrypt something.

These tools not only address unpredictable new threats, but also solve the limited resource problem faced by my organizations. Most of the ARM industry, and certainly most of the healthcare industry, does not have the manpower to dedicate a team to keep up with the new threats that are created every day. Using this next gen antivirus protection, organizations have the ability to leverage the security experts who designed and maintain the software for them.

Placing your trust, and your data, in the hands of security experts can help your organization avoid attack, even on the scale of WannaCry. For example, by leveraging the experts at Sophos CryptoGuard, we protected our healthcare clients across the country from an attack that could have suspended operations, and cost thousands of dollars to resolve.

Defense In-Depth

Behavioral analytics protection is one of what should be multiple layers of defense surrounding your patient’s PHI and financial information. More healthcare organizations should be shifting to a defense in-depth strategy, one in which layers and layers of security systems are put in place so that you are able to protect not only against incoming threats, but also against those that may already be in your system. SIEM, or Security Information and Event Management tools, funnel all security information and events into one place, providing alerts and fast response to any potential threats. RMP’s InsightIDR tool monitors our 20 million daily events and can warn our data security team of any suspicious activity, and monitor everyone already within the system to ensure all activity is sanctioned.

Play Offense, Not Defense

Protecting your system from known risks is a good way to get hacked. What we thought was ransomware yesterday is different today; we understand that more than ever after the WannaCry attack. Big organizations and healthcare systems are particularly vulnerable because of outdated technology. Protect your patients by playing offense and going above and beyond traditional protections, because you never know what new cyber-threats tomorrow brings.

Take this article with you! Click here for a printable version.

Written by Greg Haar, Data Security Officer, Chris Shelly, Cyber Security Specialist, and Ali Bechtel, Digital Marketing Manager for RMP

This information is not intended to be legal advice and may not be used as legal advice.  Legal advice must be tailored to the specific circumstances of each case.  Every effort has been made to assure this information is up-to-date as of the date of publication. It is not intended to be a full and exhaustive explanation of the law in any area, nor should it be used to replace the advice of your own legal counsel. 

Of the many emerging trends in the healthcare industry, one in particular is swiftly becoming the status quo. Hospital merger and acquisition activity jumped 70% from 2010 to 2015, and the trend is continuing upward toward a much more consolidated market. M&A is becoming increasingly critical to success as hospitals focus more on providing coordinated and cost-effective care in the face of lower reimbursement and more payer disputes.

With the creation of more integrated health systems also comes growth for revenue cycle management software and services.Continue Reading How To Ensure Your Legacy (System) in a Patient Account System Conversion

Insurance claim denials plague most hospital and medical practice billing offices, although to what extent can be hard to determine. There is a noticeable lack of information on the industry average for denied claims. Insurers are hesitant to release data about how often claims are denied, or for what reasons. So how can your billing staff know what to be on the lookout for when filing insurance claims? Continue Reading Are Claim Denials Plaguing your Practice?