Spotlighting payer best practices in the US
Dr Simon Worrell and Monica Rummelhoff talk to Lauren Haigh how businesses operating in the US can navigate the complexities of the US billing system
It’s no secret that healthcare in the US is costly. According to the World Economic Forum, in 2021, healthcare spending (including government spending) was US$12,318 per capita, making it the most expensive healthcare in the world. Yet a 2022 poll from the Associated Press-NORC Center for Public Affairs Research found that many Americans are still dissatisfied with the healthcare system. In a 2021 article, Dr Robert H Shmerling, Harvard Health Publishing, wrote: “Is the US healthcare system expensive, complicated, dysfunctional, or broken? The simple answer is yes to all.” Complexities around healthcare claims create challenges for payers and providers alike and it seems as though payers have a huge responsibility to help navigate this. “Payers are going to have to be at the forefront of figuring things out,” said Abner Mason, Founder and CEO of SameSky Health, in an interview with the Healthcare Information and Management Systems Society (HIMSS).
When approaching cost recovery best practice for international payers with exposure to US hospital bills, there are many factors to consider. Dr Simon Worrell, Founder of Chiron International, an elite global medical services company, shared with ITIJ his perspective on how assistance companies are navigating the complexities of US healthcare. “As is well known, American healthcare is amongst the best in the world. However, such excellence invariably comes with a hefty price tag,” he stated. “Over the years, experienced assistance companies have adopted several strategies to help their clients faced with expensive US claims.”
Dr Worrell said that one such strategy is the medical and operational teams paying particularly close attention to medical cases. “The progress of the patient is sought and discussed daily, if not more regularly. American hospital physicians and nurses are contacted directly where possible and signs of improvement and stability are looked for. We know that communication is paramount in any medical case and, what is more, effective communication strategies can help unnecessarily mounting costs.
“To be clear, as with all medical cases, the health of the patient is paramount and never to be compromised,” Dr Worrell underlined. “However, when the patient is stable enough to be transferred out of the US to their home country, assistance companies are often particularly keen to do this at the earliest safe opportunity.”
A common dilemma that companies next meet is how the repatriation should occur. “A patient may be stable enough to be moved but only in an air ambulance. As air ambulance repatriations themselves often attract large fees, especially from the US, an experienced medical director will consider the likely costs of an AA now, versus a cheaper commercial option following further inpatient costs after one or two weeks’ improvement on the wards,” Dr Worrell said. “This decision is often also informed by the wishes of the patient, family and company, as well as the medical competency and availability of healthcare in the receiving country. We’ve often found that as many as 10 factors must be carefully weighed when recommending the best course of action.”
A knowledgeable network
A crucial piece of the puzzle is collaboration with knowledgeable stakeholders, which is key to better understanding and navigating the complex system. Monica Rummelhoff, Executive Director, GMMI, shared with ITIJ her thoughts on the importance of industry expertise and partnerships: “To navigate the intricacies of the US billing system, businesses should prioritise developing a deep understanding of the healthcare landscape. This involves forming strategic partnerships with industry experts and professionals who have a comprehensive knowledge of the evolving regulatory environment and billing practices.”
When approaching cost recovery best practice for international payers with exposure to US hospital bills, there are many factors to consider
Robust relationships based on trust and communication can expand understanding and facilitate navigation of the system. In Abner Mason’s interview with HIMSS, he stated: “An important relationship in healthcare is between the payers and providers – the payer and their network – and they have to work together to deliver care to the patient. That relationship isn’t always easy, so having better ways for payers to understand who the best-performing doctors are and helping them shape their networks is an opportunity for payers.”
Another necessity for navigating the complex system is the implementation of advanced data analytics and technology solutions. Cutting-edge medical billing technology is playing a huge role in automating processes and streamlining, while tools such as artificial intelligence (AI) and machine learning (ML) can improve accuracy. “Utilising cutting-edge software can help in processing and analysing vast amounts of billing data efficiently,” Rummelhoff said. “This enables businesses to identify patterns, trends, and potential discrepancies in medical billing, ensuring accurate cost assessments.”
Tech can also facilitate interconnectivity among payers and their networks, and timely communication. Integrating such digital solutions, paired with continuous education and training, can help unravel the complexities of US healthcare. Staying abreast of regulatory changes and industry updates is crucial.
“Regular training programmes for staff, especially those directly involved in billing and claims processing, can ensure that the team is equipped with the latest knowledge and skills to handle the complexities of the US billing system,” Rummelhoff highlighted.
Cost recovery strategies
Once the patient has been repatriated, it’s time to consider the costs. “To help with this, we have used US agents with great effect over the years. It’s been our experience that these agents not only help with getting the patient rapidly accepted and admitted in US hospitals and encourage good flow of medical information, but are also able to negotiate very significant reductions in the final bill. A true win-win,” said Dr Worrell.
Rummelhoff agreed that the right partnerships can prove indispensable: “Engage in proactive negotiations with healthcare providers to secure reasonable and transparent rates for services. Establishing strong relationships with a network of preferred providers can contribute to more favourable cost recovery outcomes,” she stated.
Offering personalised solutions can enhance client satisfaction and build long-term relationships
Rummelhoff also highlighted the importance of engagement with regulatory authorities: “Establishing open lines of communication with regulatory bodies and payers is key. Actively engaging with these entities helps businesses stay informed about policy changes, compliance requirements, and industry best practices, allowing for proactive adjustments to their operations.”
Is part of the complexity due to inadequate enforcement of regulations? A 2023 article by Larry Levitt and Drew Altman published on JAMA Health Forum said: “The regulatory structure largely already exists to require explanations of benefits that make sense to consumers, clinician directories that are accurate, and rights to appeal when claims are denied. What is missing is effective enforcement of these requirements and support for consumers (especially those with serious and chronic health conditions) to comprehend and navigate the complex labyrinth the US health insurance system has become.”
Comprehensive audit processes are paramount, as Rummelhoff explained: “Conducting thorough reviews and audits of medical claims is essential for identifying overcharges, billing errors, and potential fraud. Implementing robust auditing processes helps in maximising cost recovery efforts and ensuring that payments are accurate and fair. We have a robust program that allows us to ensure we have the proper flags in place.”
Part of GMMI’s cost containment strategy includes the detection and prevention of fraud, waste and abuse through data analytics using ‘usual, customary and reasonable’ (UCR)/Medicare benchmarking; claims auditing; Office of Foreign Assets Control (OFAC) screening; and payment integrity through analytics for coding validation, unbundling and National Correct Coding Initiative edits. Legal and regulatory compliance is also extremely important, as Rummelhoff went on to highlight: “This involves ensuring that all cost recovery efforts align with legal and regulatory frameworks. Adhering to compliance standards is crucial for maintaining trust with stakeholders and avoiding legal complications.”
Meeting the needs of clients and patients
Tailoring cost recovery strategies to the unique needs of the client is important, as a bespoke solution really takes into account client wants and needs and is beneficial in both the short and long term. “We are proactive in coordinating benefits with other payers and therefore strongly recommend that the policy language supports this effort. Additionally, we explore opportunities to subrogate when possible,” said Rummelhoff. “Offering personalised solutions can enhance client satisfaction and build long-term relationships, positioning the company as a trusted partner in managing healthcare costs.”
With the right strategies, solutions and connections in place, navigating the intricacies of US healthcare needn’t be a headache. “Receiving good healthcare in America will never be cheap, but the costs don’t have to be so eye-watering if assistance companies are experienced in the US, giving particularly close attention to patients and their progress,” said Dr Worrell.
But the approach must be proactive and given constant attention, Rummelhoff concluded: “Understanding the complexities of the US billing system requires a multifaceted approach that combines industry expertise, technological solutions, continuous education, and proactive engagement with regulatory bodies. When it comes to cost recovery payments, a strategic combination of audit processes, negotiation strategies, technology utilisation, legal compliance, and client-centric solutions can contribute to success.”