For patients responsible for out-of-pocket costs associated with high-deductible health insurance plans, the financial burden associated with rheumatologic care can become overwhelming. Meanwhile, collecting payments for services is critical for a rheumatology practice to stay in the black.
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As a rheumatologist working in a private practice in North Charleston, S.C., Colin Edgerton, MD, FACP, RhMSUS, has found several important keys to engaging in positive and productive financial dialogue with patients. Here are his suggestions for broaching the payment conversation
1. Focus on Access
Dr. Edgerton finds that addressing access is the key to any financial discussion with a patient.
“I seek to inform the patient about what treatment, test or other service is recommended, and then start to discuss the possible financial impact,” he explains, noting this can be difficult because “we may not generally know what financial impact services will have on the patient until such services have been ordered.”
This financial piece is just one more reason a successful practice has to maintain communication with a patient after their visit, Dr. Edgerton stresses. “This open conversation allows for back-and-forth discussion regarding any difficulties the patient may face, such as prior authorization, which is currently the most challenging financial aspect of care we are seeing,” he says.
2. Outline the Costs the Practice Does Not Control
“It’s important to help patients clearly understand that we do not control the cost of most medical services, such as labs, medications and radiology. And we generally do not know what portion of these services their insurance may cover and what their remaining out-of-pocket responsibility may be,” Dr. Edgerton says. “We do encourage patients to inform themselves of their insurance benefits and to communicate with their insurer.”
Despite encouraging direct contact between a patient and their insurer, Dr. Edgerton finds that his practice is far more receptive than an insurance company. “Patients often bring their insurance questions and problems to us,” he says.
3. Coordinate Practice Support for a Financial Discussion with Patients
Although it’s a financial burden to the practice, Dr. Edgerton says his practice has several full-time staff members who help patients navigate financial issues.
“We have found there’s no other way. Patients consistently have a very difficult time communicating with their insurers and generally do not have the sophistication to navigate the details of their insurance plans,” Dr. Edgerton says. It seems as if insurance plans are designed to “triage by hassle,” making it difficult for patients to obtain higher cost services.
To help patients, Dr. Edgerton points to the work of the ACR in speaking out about onerous cost mitigation strategies, such as step therapy and prior authorization. Example: The ACR is supporting legislation to modernize prior authorization to ensure it becomes standardized and supports electronic options, requires insurance to be transparent about coverage restrictions and eliminates prior authorization for the therapies that are most often approved.
The ACR also continues to advocate against step-therapy that does not put patients first. Legislation currently supported by the ACR regarding step therapy recommends a clear and transparent process for patients to seek exceptions to step-therapy in certain cases, as well as establishes a reasonable and clear timeframe for override decisions that take into account the patient’s medical history and the provider’s expertise before denying a patient medically necessary treatment.
Carina Stanton is a freelance science writer based in Denver.
Visit the ACR’s Legislative Action Center to follow current bills and share your patient’s financial challenges with step-therapy, prior authorization and other financial concerns with insurance coverage.