Trends in Healthcare Payments Annual Report: 2012

Transcription

1 Trends in Healthcare Payments Annual Report: 2012 Published: March 2013

2 CONTENTS 3 Executive Summary 4 Trends in Payer Payments 7 Trends in Patient Payments 9 Provider Sentiment 12 Payer Sentiment 14 Patient Sentiment 16 Latest Trends and Best Practices 19 Conclusions 19 Methodology 19 About InstaMed InstaMed 1880 JFK Boulevard, 12th Floor Philadelphia, PA (866) INSTAMED All content, including text, graphics, logos, icons, images and the selection and arrangement thereof, is the exclusive property of InstaMed and is protected by U.S. and international copyright laws. No portion of this document may be reproduced, modified, distributed, transmitted, posted or disclosed in any form or by any means without the express written consent of InstaMed. 2

3 EXECUTIVE SUMMARY The U.S. healthcare payments market is growing and changing rapidly in fact, it is estimated to have reached $2.7 trillion as a total of both payer and patient payments. 1 A great deal of this growth has spurred from increasing patient responsibility, as high-deductible health plan (HDHP) enrollment has increased nationally from one million to more than 11 million since If patient payments are not managed correctly, they can cost three to five times more to collect than payer payments due to paper-based, manual processes. These costs are further escalated by rising patient bad debt, which was estimated to have been more than $65 billion in The evolving healthcare payments industry impacts the way payers do business as well. Existing and upcoming healthcare reform mandates require payers to make changes to support standardized electronic healthcare transactions such as electronic remittance advice (ERA) and electronic funds transfer (EFT). Some payers have already begun to leverage technology to support ERA/EFT in order to reduce their administrative costs, as the current manual and paper-intensive process to disburse payments contributes to inefficiencies and costs of more than $300 billion each year. 4 The 2012 Trends in Healthcare Payments Annual Report demonstrates the business drivers for payers and providers and the changes they are making to operate efficiently and maintain cash flow. This report presents key market trends impacting the healthcare payments industry from an objective view in order to educate the market and promote awareness, change and greater efficiency. This report showcases quantitative data processed on the InstaMed Network and features trends based on qualitative data obtained from healthcare providers, payers and patients nationwide. KEY POINTS As payment responsibility continues to shift from payers to patients, providers and payers are driven to expand patient payment channels. Although ERA/EFT transactions have increased, many payers still need to implement the technology to achieve compliance with the 2014 ERA/EFT mandate. Provider organizations continue to consolidate, which drives a greater need for system interoperability for healthcare payments. As the industry expands patient payment channels, private cloud technology will be crucial to enable an efficient payment process. If patient payments are not managed correctly, they can cost three to five times more to collect than payer payments. 3

4 TRENDS IN PAYER PAYMENTS Healthcare reform and consumerism coupled with rising administrative costs and inefficiency are drastically changing the payment process between payers and providers. It is projected that member premiums will reach 7.9 percent by 2014 as more employers switch to low-cost, high-deductible health plans. 10 Data from the InstaMed Network confirms this overall increase in patient responsibility and, consequently, an overall decrease in payer-to-provider payments. In 2010, payers paid providers an average of 23 percent of the billed charges, which decreased to 20 percent in 2012 (Figure 1.1). Figure 1.1 Payer-to-Provider Payments 30% Percentage of Billed Charges 25% 20% 15% 10% 5% 0% Year 4

5 Effective January 1, 2014, the Patient Protection and Affordable Care Act (PPACA) mandates that all payers support ERA/EFT, which electronically combines the healthcare payment information and the payment to automate provider posting and reconciliation. Many payers have implemented ERA/EFT prior to the mandate in order to cut costs and improve efficiency by reducing paper and manual work in the disbursement process. These benefits motivate payers to adopt ERA/EFT as soon as possible, and data from the InstaMed Network confirms this trend. In 2010, the transaction count of payer payments disbursed via EFT was 46 percent of all payer payments, which increased to 51 percent in 2012 (Figure 1.2). Figure 1.2 Payer-to-Provider EFT Payments 70% Percentage of EFT Transactions 60% 50% 40% 30% 20% 10% 0% Year 5

6 As more payers offer ERA/EFT, more providers accept these electronic and paperless transactions to get paid faster and improve efficiency by automating posting and reconciliation. Payers that offer ERA/EFT are promoting electronic adoption among their provider networks through outreach and enabling multiple registration methods in order to increase cost savings. Data from the InstaMed Network shows that targeted promotional campaigns have effectively increased provider adoption of ERA/EFT. In 2011, payers leveraging the InstaMed Network to promote ERA/EFT to their providers achieved an average of 44 percent provider adoption, which increased to 62 percent in 2012 (Figure 1.3). Figure 1.3 Provider ERA/EFT Adoption 100% Paper Check and EOP ERA/EFT 90% Percentage of Payer Payments 80% 70% 60% 50% 40% 30% 20% 10% 0% Year 6

7 TRENDS IN PATIENT PAYMENTS As payer responsibility is decreasing, inversely, patient payment responsibility is rising. Copays, deductibles, balance billing and self-pay all contribute to the five to six percent annual growth in patient out-of-pocket healthcare spending. 11 And in 2014, the number of patients in the U.S. healthcare system will drastically increase as approximately 30 million uninsured Americans will begin to receive healthcare coverage under PPACA. Data from the InstaMed Network confirms this trend, as patients were responsible for an average of 20 percent of the allowed charges in 2010, which increased to 23 percent in 2012 (Figure 2.1). Figure 2.1 Patient Responsibility 30% Percentage of Allowed Charges 25% 20% 15% 10% 5% 0% Year 7

8 As patients represent a growing portion of provider revenue, providers need to meet patient payment expectations set by other industries, such as offering convenient payment options including online payments. In addition to increasing payments, online payment methods reduce costs for providers by decreasing the number of statements and follow-up activities needed to collect. Therefore, providers are offering an online payment option and promoting it to patients to increase cost savings. According to data from the InstaMed Network, in 2010, online patient payments represented eight percent of the gross dollar volume of all patient payments, which increased to 13 percent in 2012 (Figure 2.2). The growing use of online payments confirms that patients are willing to pay their healthcare bills online when given the option. Figure 2.2 Online Patient Payments 14% 12% Percentage of Dollar Volume 10% 8% 6% 4% 2% 0% Year 8

9 PROVIDER SENTIMENT Based on the data surrounding both payer and patient payments, it is apparent that providers are impacted by these trends. To better understand the experiences of providers, InstaMed conducted a nationwide healthcare provider survey. The survey participants ranged from solo practitioners to billion dollar health systems. The following are the key data points from the survey: Figure 3.1 In 2012, 75 percent of providers indicated that they saw an increase in patient responsibility. 39% 36% 20% 3% 2% Significantly increased Slightly increased No change Slightly decreased Significantly decreased Figure 3.2 In 2012, only 41 percent of providers said they collected payments at the point of service for the majority of their patient visits. When they did not collect at the point of service, 41 percent said it was due to uncertainty of the amount due, while 35 percent said it was due to patient resistance to pay. 41% 36% 14% 9% Most of the time Some of the time Rarely Never 41% 35% 15% 4% 3% 2% Uncertainty of amount due Patient resistance Other No point of service (e.g., anesthesiologist) Did not accept credit cards Time consuming 9

10 Figure 3.3 In 2012, 49 percent of providers said they did not know patient responsibility during the patient visit. 51% 49% Patient responsibility was known Patient responsibility was unknown Figure 3.4 In 2011, 81 percent of providers said it took more than one month to collect from a patient after claim adjudication, which increased to 83 percent in % 27% 11% 8% 6% 3% 1 2 months 2 3 months Unsure More than 4 months Less than 1 month 3 4 months Figure 3.5 In 2012, 89 percent of providers said they offered the option of payment plans to their patients. Of the providers that did not offer payment plans, the primary reason was due to a lack of payment automation with payment plans. 89% Yes 11% No 45% Payments couldn t be collected automatically 22% Cost 11% Time consuming 11% Posting/reporting would be too complicated 11% Other 0% Payment security concerns 10

11 Figure 3.6 In 2012, 70 percent of providers said they received some of their payer payments electronically. Of the providers that received payer payments electronically, the majority said they received payments via EFT, and some received payments via virtual card. Additionally, 88 percent of providers said they received ERAs from payers in % 30% Received payer payments electronically Did not receive payer payments electronically Figure 3.7 Of the providers that did not receive payer payments electronically, 63 percent said it was because payers did not support electronic payments. 63% 25% 8% 4% 0% 0% Not supported by payer Other Too much paperwork Did not have the technology to support it Potential for unauthorized withdrawal Paper checks preferred 11

12 PAYER SENTIMENT Healthcare payers are also greatly impacted by the trends in healthcare payments. To better understand the experiences of payers, InstaMed conducted a survey of healthcare payers nationwide. The following are the key data points from the survey: Figure percent of payers said they offered ERA/EFT to their providers. 66% 17% 14% 3% ERA/EFT offered In the process of implementing ERA/EFT Neither ERA only offered Figure 4.2 Of the payers that did not offer ERA/EFT to their providers, 38 percent said it was due to cost concerns. 38% 25% 13% 12% 12% Cost concerns Other Resource constraints Technology barrier Not a priority Figure percent of payers said they have begun planning for the upcoming ERA/EFT mandate. 76% 24% Have begun planning for mandate Have not begun planning for mandate 12

13 Figure 4.4 When questioned about their top issue when dealing with their provider networks in 2012, 45 percent of payers said it was reconciliation of claim remittances and check/eft payments, and 28 percent said it was claim adjustments and prior payment reconciliation. 45% 28% 17% 3% 7% Reconciliation of claim remittances and check/eft payments Claim adjustments and prior payment reconciliation Claim resubmissions/duplicate claims Call center volumes Other Figure 4.5 When questioned about their top priority for 2013, 41 percent said legislative technology-based regulations, such as PPACA. One year ago, the most popular response to this question was ICD % 14% 10% 7% 7% 7% 7% 7% Legislative technology-based regulations (PPACA, CAQH CORE) IT upgrades/system changes Other legislative regulations (ACOs, HIEs, PCMH) ICD-10 Analytics/business intelligence Care management Cost reduction strategies Other 13

14 PATIENT SENTIMENT The 2012 trend data indicates that patients have become an important constituent in healthcare payments. To better understand the experiences of patients, InstaMed conducted a national patient survey for patients who visited a healthcare provider in The following are the key data points from the survey: Figure percent of patients said they did not know their payment responsibility following a visit. 78% 22% Payment responsibility was known Payment responsibility was unknown Figure 5.2 Only four percent of patients said they received their healthcare bills via in % 4% Mail Figure 5.3 In 2011, 55 percent of patients said they normally paid their monthly bills online, such as utility or cable bills, which increased to 62 percent in % 25% 8% 3% 2% Online bill pay Mail check Credit card Cash Phone 14

15 Figure percent of patients said they would be interested in paying their healthcare bills online. 72% 28% Interested Not interested Figure 5.5 In 2011, 63 percent of patients said that if they had the option of paying their healthcare bills via a monthly payment plan, they would use this option, which increased to 71 percent in % Would only use payment plans for larger bills 29% Would rather make a one-time payment 28% Would use payment plans whenever possible 15

16 LATEST TRENDS AND BEST PRACTICES Preparing for the Upcoming ERA/EFT Mandate Only six percent of payers surveyed said they had a strong understanding of the ERA/EFT operating rules. 5 Effective January 1, 2014, all payers will be mandated to support ERA/EFT. While nearly two-thirds of surveyed payers stated that they already support ERA/EFT, all payers need to ensure that they will be compliant with the operating rules developed by CAQH CORE, which define requirements around uniform use of claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs), ERA/ EFT enrollment standards, ERA/EFT association standards, and claim payment/remittance infrastructure standards. To learn more about the ERA/EFT operating rules, visit: More than 50 percent of all payer-to-provider payments processed on the InstaMed Network are EFT payments. While ERA/EFT transactions increased in 2012, many payers will still be implementing the technology to meet the ERA/EFT mandate in When evaluating how to achieve ERA/EFT, one of the first decisions a payer will make is to build or buy whether to use internal resources to build ERA/EFT capability or to buy from a third-party vendor. Regardless of which model a payer follows to achieve ERA/EFT, there are several key considerations that should be included in the project scope from the beginning: Provider Adoption Reach providers easily to enroll them in ERA/EFT quickly and minimize print and mail costs. Financial Controls and Daily Monitoring Establish dedicated resources and processes to monitor all payment activity on a daily basis, support financial regulatory requirements, protect against fraud when enrolling providers, and support bank account changes and Know Your Customer (KYC) verifications in a timely manner. Compliance Requirements To avoid penalties, identify resources to understand the mandated operating rules and verify that the payer is compliant. Third-Party Relationships If payers choose to work with a vendor, they need to make sure they know who they are buying from and any downstream, third-party relationships that the vendor may require to deliver a complete solution. It is crucial for a payer to understand all of the relationships in scope, which will help to assess points of failure, risks and the continuity of service for dealing with difficult issues that arise in an electronic processing environment. To learn more about building vs. buying ERA/EFT, visit: 16

17 Simplifying the Patient Payment Experience 37 percent of providers surveyed said their primary revenue cycle concern is the increase in patient responsibility. As patient responsibility continues to rise, patients have more influence in the healthcare payments process. Both providers and payers will shift their focus to delivering more channels for consumer payments so that providers collect more and payers increase provider and member satisfaction. 83 percent of providers surveyed said it took more than one month to collect from a patient after claim adjudication. Today, providers send out multiple paper statements and make follow-up phone calls to collect patient responsibility. Facilitating payments at every patient interaction point will be a key factor in decreasing provider days in accounts receivable and reducing the time and costs to collect. 72 percent of patients surveyed said they would like to be able to pay their healthcare bills online. It is estimated that consumers in the U.S. will spend more than $300 billion online in To collect more patient payments, healthcare will look to the online payment best practices used in other industries to meet patient payment expectations as consumers. To learn more about online patient payment best practices, visit: New Ways to Engage with Patients In addition to leveraging technology and new processes, providers will focus on fostering cultural changes among staff and patients to better prepare staff members to collect and patients to pay. Tools and policies such as prompt pay discounts, staff incentive programs, minimum payment requirements and scripts to use when discussing payments with patients will be effective as providers need to collect more from patients. Expanding Interoperability to Healthcare Payments 71 percent of providers surveyed said the lack of system interoperability is a major barrier to health information exchange. 7 Consolidation in healthcare will continue as larger provider organizations acquire practices and clinics, driving a greater need for system interoperability. Many organizations are already focused on the interoperability of clinical information; however, the industry will need to expand its focus to the administrative side of healthcare, including payment-related systems and processes. By integrating heterogeneous systems, providers and payers will automate more processes, simplify compliance requirements and streamline employee training. 17

18 Increased Focus on Data and Security In 2012, the number of payment locations on the InstaMed Network grew by 148 percent. In the last decade, cloud usage in the U.S. has grown by more than 150 percent. 8 As providers and payers deliver more channels for consumer payments, private cloud technology will be crucial to enable providers to efficiently collect, post and reconcile all payments. However, while moving to the cloud greatly enhances the way organizations can facilitate payments, it also presents new risks such as long-term downtime and loss of data in the event of a disaster. To protect data in the cloud, it will be an organization s responsibility to ask its cloud vendor about disaster recovery and prevention policies and procedures. To learn more about questions to ask cloud vendors, visit: In 2012, 27 percent of all reported data breaches occurred in the healthcare industry. 9 With the increase in payment card payments from patients and payers, the risk of a payment card data breach may also increase. The financial and reputational costs of a payment card data breach are high and may result in bad publicity and loss of business. To reduce the risk of a breach, organizations will need more effective methods to achieve payment card security and to meet the Payment Card Industry (PCI) standards more easily. In order to protect sensitive information when collecting payments, organizations will need to leverage new technology such as encryption at the point of interaction (POI) and prepare for the upcoming mandate around EMV, which adds another layer of authentication. To learn more about payment card security, visit: 18

19 CONCLUSIONS The data from the 2012 Trends in Healthcare Payments Annual Report demonstrates that the healthcare payments industry is continuing to evolve, and that many providers and payers have already taken steps to accommodate for these changes. In order for all stakeholders to thrive as the industry evolves, they must be aware of how the industry is changing, acutely understand the challenges and apply process and policy changes to prepare. Efficiency, payment best practices, interoperability and security will be crucial to all industry stakeholders as the industry continues to change. METHODOLOGY The 2012 Trends in Healthcare Payments Annual Report includes quantitative data from over $60 billion in healthcare payments volume on the InstaMed Network, which powers healthcare and payment transactions for a wide range of providers, from solo practitioners to billion dollar health systems, and payers of all sizes nationwide. The data represented was processed between 2010 and In addition, this report includes qualitative market data. The provider sentiment data comes from respondents representing over 60,000 healthcare providers nationwide. The group of respondents is comprised of 52 percent medical practices or clinics; 20 percent durable medical equipment (DME) providers, labs or other offices; 16 percent billing services; and 12 percent hospitals, health systems or integrated delivery networks (IDN). The payer data comes from respondents representing over 3,000 payers nationwide. The group of survey respondents is comprised of 41 percent regional payers; 29 percent third-party administrators (TPA); 15 percent Blue Cross Blue Shield plans; 11 percent Medicaid/ Medicare plans; and four percent health maintenance organizations (HMO). The patient data comes from respondents representing over 200 patients nationwide who visited a healthcare provider in ABOUT INSTAMED InstaMed simplifies every healthcare clearinghouse and payment transaction for providers and payers, all in one place. InstaMed enables providers to collect more money, get paid faster and reduce the time and costs to collect. InstaMed allows payers to cut settlement and disbursement costs with electronic payments. InstaMed s single, integrated network simplifies the healthcare payments process for 1,500+ hospitals, 60,000+ practices/clinics and 100+ billing services; connects to 3,000+ payers; and integrates with 50+ practice management systems. InstaMed processes tens of billions in healthcare payments each year at a rate of more than $1,000 per second. Visit InstaMed on the web at Sources: 1 IDC Health Insights (2011) 2 AHIP (2011) 3 McKinsey Quarterly (2010) 4 McKinsey Quarterly (2007) 5 InstaMed and CAQH CORE ERA/EFT Webinar (2013) 6 Forrester (2012) 7 Bipartisan Policy Center (2012) 8 Internet World Stats (2012) 9 ITCR Breach Report (2012) 10 Centers for Medicare and Medicaid Services (2011) 11 U.S. Department of Health and Human Services 19

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