As per federal government law the patient may not be refused healthcare services for emergency situations even if they do not have insurance coverage details. Patients register themselves as self-pay even when they do have an active healthcare insurance due to many factors such as
- When the patient is unaware of the plan coverage and benefits that their active insurance coverage may offer
- The current insurance coverage may have high deductibles and Out Of Pocket (OOP) expenses
- Patient may not have their plan and coverage details handy at the time of service
- During emergency situations the patient may not be in a condition to share the required details for the paper work
- Patient may not have the required funds to cover for the medical procedure
- The insurance coverage may have plan restrictions and will not be able to pay the healthcare provider for the services rendered. Especially for HMO plans, the insurance will require the patient to visit an in-network primary care physician before reaching out to the specialists via a referral. The deductibles are high in a HMO plan and at certain plans the patient may not have Out of Network coverage. In a Preferred Provider Organization (PPO) plan the patient is free to visit any healthcare provider within the group, however higher out of pocket expenses may be applicable.
- Referrals can also be problematic when the patient seeks referrals to specialists and the payor may have plan restrictions
- The benefits on the current insurance coverage may be exhausted or reached the maximum benefits and the insurance payors will not cover for the services
- Self-pay patients might not believe that they have coverage, however it’s possible that some are hidden beneath layers of paperwork and redtape.
In many cases, patient’s who start as self-pay patients do not remain as self-pay due to changes in their lifestyle and they could afford a healthcare insurance or they may be enrolled in the state’s Medicaid program.
Huge outstanding on the self-pay financial class is usually not a good sign of a healthy practice. Claims in self-pay financial class takes more time for resolutions and reimbursement to the healthcare provider. In certain cases the reimbursement for the services may not be paid by the patient and may end up as bad debt eventually being written off the books.
The Insurance Discovery tool provides support in retrieving the active insurance coverage of the patient along with the coverage and benefit details. The precise information retrieved helps in converting self-pay claims into insurance responsibility if the patient has any valid insurance coverage. Identifying the correct insurance payor where the claim needs to be sent to reduces the reimbursement time and AR days. The Insurance Discovery tool goes a step ahead and retrieves the Co-Ordination Of Benefits (COB) information of the patient in case of multiple payor involvement.
In brief the Insurance Discovery tool facilitates in the conversion of self-pay patients who may voluntary or in-voluntary register them as self-pay patients into patients aided by insurance coverage. The retrieved information helps the billing office to understand the coverage, benefits and aid in providing insights for decision making in identifying the responsible party for the healthcare services rendered.
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