Highmark providers, such as primary care physicians, specialists, healthcare facilities and hospitals, now have access to tools to assist them in discussions with Highmark members about out-of-pocket costs.
"Over the last few years, we have seen continued growth in cost-sharing health plans such as those with high deductibles or coinsurance," said Robin Bugni, Highmark's director of strategic products.
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.
"Without tools like our real-time capabilities, it's difficult for providers to give accurate information to members about what the cost of a healthcare service will be," said Bugni. "Some providers are trying to estimate what the member will owe without a claim processing against their benefit plan."
Real-time capabilities allow Highmark members with high deductibles, co-insurance or other types of cost-sharing to better understand the actual cost of healthcare services. Approximately 730,000 Highmark members in Pennsylvania are currently enrolled in health plans with cost sharing that includes deductibles and/or co-insurance for in-network services.
Real-Time Provider Estimation allows the provider to submit requests for specific healthcare 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 used 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.
The costs to a member are calculated based upon the members' specific health plan, taking into consideration their co-payments, co-insurance, deductibles and other benefit structures.
"We know that on average providers collect 50 percent of patient financial liability," said Bugni. "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 co-insurance costs."
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.