Pittsburgh — Thanks to two new real-time tools, Highmark providers now can assist discussions with Highmark members their out-of-pocket costs. Highmark, a Pittsburgh-based independent licensee of the Blue Cross and Blue Shield Association, says the tools, Real-Time Provider Estimation and Real-Time Claims Processing, are the first such tools in the region offered by an insurer. Some 250 providers across Highmark’s service area will begin using the real-time tools, which are designed to give providers the ability to set payment expectations with members during the initial roll-out period, which started in November.

With real-time capabilities, providers can send an electronic claim to Highmark and receive a response indicating the amount the Highmark member owes. Providers can use these tools prior to service or at the point of service, and then have the option to collect this payment or make payment arrangements with the member at the time services are received.

For example, if a Highmark member were scheduled to receive an x-ray, the provider could use Highmark’s real-time capabilities to estimate the cost of the x-ray to the member taking into account their specific health benefit design, including deductibles and coinsurance. The member would then have a clear understanding of their financial responsibility for the service, and would be prepared to make any necessary payments to the provider.

These real-time capabilities allow Highmark members with high deductibles, coinsurance or other types of cost-sharing, to better understand the actual cost of health care services. Approximately 730,000 Highmark members in Pennsylvania are currently enrolled in health plans with cost-sharing that includes deductibles and/or coinsurance for in-network services.

“Over the last few years, we have seen continued growth in cost-sharing health plans such as those with high deductibles or coinsurance,” says Robin Bugni, Highmark director of strategic products. “To help our members become true ‘consumers of health care,’ Highmark is taking the next step in the evolution of consumerism by helping our members to understand their actual out-of-pocket health care costs when they schedule and receive health care services. With Highmark’s new real-time capabilities, providers can discuss these costs with patients and make payment arrangements at the time care is delivered.”

Real-Time Provider Estimation allows the provider to submit requests for specific health care services—before a member receives care or at the time of service—and estimate the member’s financial responsibility within seconds. This, in turn, can be utilized to address the member’s desire to know the cost prior to receiving services, and collect or make arrangements for payment at the time care is delivered.

Real-Time Claims Processing gives providers the added ability to submit claims for specific health care services and receive a fully processed claim response within seconds. This, in turn, enables the provider to collect or arrange for payment of the member’s share of the cost at the time service is provided.

The costs to a member are calculated based upon the members’ specific health plan taking into consideration their copayments, coinsurance, deductibles and other benefit structures.
Some 250 providers across Highmark’s service area will begin using the real-time tools during the initial roll-out period, which started in November. In April 2009, all Highmark providers with access to Highmark’s provider portal will be able to use the real-time capabilities.

“Without tools like our real-time capabilities, it’s difficult for providers to give accurate information to members about what the cost of a health care service will be,” says Bugni. “Some providers are trying to estimate what the member will owe without a claim processing against their benefit plan. Real-time capabilities from Highmark will give our members the added assurance that the information has been calculated using their benefits and their claims payment history for that year.”

Real-time tools also have an administrative benefit for providers, as they will allow providers to avoid billing, collecting payment after the patient leaves or writing off unpaid balances.
“We know that on average providers collect 50% of patient financial liability,” Bugni says. “Providers who use Highmark’s real-time capabilities will be able to set clear payment expectations with the member prior to or at the point-of-service and better collect the members’ deductible and coinsurance costs.”

Source: Highmark

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