Price Transparency

The growing shift from inpatient to outpatient care continues. The U.S. ambulatory services market was estimated at USD 289.5 billion in 2023 and is projected to grow at a CAGR of 5.38% from 2024 to 2030. A Deloitte study notes that the gap between inpatient and outpatient revenue has been closing for two decades. But what's driving this boom? Clinical advances, patient demand for lower-risk and lower-cost options and payer pressure all play a role. New technologies, like advances in orthopedics, allow more procedures to be performed at outpatient service centers instead of costly hospital settings. Free-standing ambulatory surgery sites are expected to see a 14% volume boost over the next decade as more service lines, like cardiovascular and neurosciences, begin to shift procedures from inpatient to outpatient facilities. The ongoing growth in outpatient services presents a unique opportunity for revenue cycle leaders to use technology to improve outpatient revenue—and the overall patient experience. Grow outpatient revenue with more digital care Patients want a better experience at every step of the patient journey. They want to see their doctor faster, manage appointments online and understand how much it costs—with as little red tape as possible. A lack of streamlined patient access and transparency often results in no-shows, a rise in claims denials, wasted staff time and patient complaints. However, by opening the digital front door, providers can give patients the self-service tools they crave, improve the care experience, keep outpatient schedules full and increase revenue. Additionally, providers can use technology like artificial intelligence (AI) to lower claim denial rates. Here are five strategies to increase outpatient revenue in 2025. 1. Make patient access simple Patients want to see their doctor faster. In Experian Health's latest State of Patient Access survey, eight in ten patients who reported being unhappy with their provider experience cited waiting for an appointment as a top complaint. When trying to schedule, patients are also frustrated by the friction that comes with complex processes, clunky technology systems and sparse provider communication. Outdated manual workflows, staffing shortages and lack of staff training often result in challenges for both patients and providers. Improved patient access is at the heart of patient-centered healthcare. Technology designed to put the patient in control, like online patient scheduling and digital patient intake tools, offer continuous patient engagement, optimized scheduling, and streamlined administrative processes. By leveraging modern patient access solutions, providers can improve patient experiences and alleviate the impact of staffing shortages. 2. Reduce appointment no-shows Missed appointments cause headaches for patients, providers, and revenue cycle managers. Online scheduling and mobile registration are also top of mind for patients. In Experian Health's State of Patient Access 2024 survey, 89% of patients said they wanted self-service scheduling and 85% reported a dislike for filling out repetitive intake paperwork. Online patient scheduling software puts patients in the driver's seat, providing convenient and secure 24/7 access to book, reschedule, and cancel appointments on their own time. Solutions like Patient Schedule sync seamlessly to an organization's scheduling rules, and patients receive automated appointment reminders by text or IVR. On average, providers that use Experian Health's scheduling solution experience an 89% show rate, a 50% reduction in scheduling time, and a 32% increase in patients per month. Patient intake tools like Registration Accelerator simplify mobile registration with a streamlined text-to-mobile experience. Once registration is complete, automated returns of forms, patient-check-ins and demographic information ease the burden on staff. 3. Help patients prepare for outpatient costs Patients need a clear breakdown of their financial responsibility before receiving care. Without it, they may be unable to prepare for care costs appropriately. While hospitals are now required to share detailed pricing for at least 300 common procedures, confusion around a patient's actual financial responsibility still persists. More than half of patients report turning to their provider for help understanding what insurance covers. Digital solutions that provide accurate, upfront estimates empower patients. More than eight in ten patients say pre-service estimates help them prepare for the cost of care. Patient Payment Estimates provide upfront, real-time estimates of what a patient will owe. Providers can offer convenient and secure payment links, and allow patients to pay their bills online or see customized payment plans. Outpatient providers can further maximize the chance of reimbursement by running health insurance coverage checks across the entire revenue cycle. This can help find billable coverage that may have been forgotten and give patients greater certainty about what they'll owe. 4. Automate healthcare collections Collections are often a major challenge in the outpatient revenue cycle. Outpatient procedures can be costly, even with insurance, leaving patients responsible for potentially large bills. Automating healthcare collections allows for faster, more efficient, and more compassionate collections. Tools like Collections Optimization Manager helped Novant Health achieve an overall recovery rate of 6.5% and increase revenue and cost savings to a rolling average return on investment of 8.5:1. With automated tools like Patient Financial Clearance, providers can assess patients' ability to pay and assign them to an appropriate financial pathway. This allows patients to quickly get the assistance they need while freeing up valuable staff time. 5. Streamline claims to increase outpatient revenue Denied claims continue to be problematic for providers. In Experian Health's State of Claims 2024 report, which surveyed 210 healthcare revenue cycle leaders, nearly three-quarters of providers feel claims denials are increasing, while 67% feel getting paid is taking longer. Claims management software can help end the cycle of denials. However, around half of providers still use a manual claims review process, and only 28% feel confident in their understanding of automation, machine learning and AI. Adopting automated and integrated healthcare claims management solutions can reduce errors, prevent undercharges, and ensure a higher first-pass payment rate. Tools like Experian Health's ClaimsSource® simplify the entire claims process, while Claim Scrubber helps providers submit more accurate claims. Digital solutions can also automate claim status monitoring and eliminate manual denial processes. Implementing AI tools to interpret past claims data and recommend next steps can improve outpatient claim denial statistics. Tools like AI AdvantageTM look at past payer behavior and historical claims data to predict and prevent denials. AI Advantage's two components, Predict Denials and Denial Triage, help providers respond to growing denial challenges by identifying claims with a high likelihood of denial before submission, and focus on remits that have the most impact. See how: Find out more about how Experian Health's revenue cycle management solutions can help healthcare organizations increase outpatient revenue, keep pace with growing patient volumes, improve patient satisfaction and boost their bottom lines. Learn more Contact us

As more Americans feel the squeeze on their household budgets, paying for healthcare is a growing concern. A 2024 survey by Pew Research Center found that the number of Americans who rate their personal finances positively has dropped from 50% to 40% over the last three years, with nearly 60% of Americans now saying their financial situation is "fair" or "poor." A West Health-Gallup poll revealed that 35% of US adults would struggle to afford care, with some cutting back on essentials like utilities or food to pay for medical expenses. To address and mitigate these financial pressures, healthcare providers must take proactive steps to support patients and avoid a shortfall in collections. Patient payment plans can help patients manage costs without delaying or skipping necessary care. Providers that go the extra mile to improve the patient experience will boost patient attraction and retention rates, reduce collection costs and support the financial health of their patients and their organizations. The growing importance of healthcare payment plans Cost concerns often influence patients' perceptions of their providers. In Experian Health's State of Patient Access 2024 survey, 54% of patients who thought patient access had deteriorated over the previous twelve months said it was because they were less able to afford care. On the flip side, 32% of those who thought patient access was better said it was because payment plans made care more manageable. Healthcare payment plans allow patients to spread out the cost of their medical expenses into smaller, more manageable chunks, instead of paying the full amount at once. Previous research by Experian Health and PYMNTS confirms that patients welcome the flexibility, convenience and reassurance that this offers. This is particularly true of patients who would struggle to pay an unexpected bill: up to a fifth of these patients would switch providers based on the payment experience alone. The clear message for providers is that patients who struggle to pay bills—especially unexpected bills—are more likely to need healthcare payment plans and to seek out a provider that offers them. How flexible patient payment plans improve satisfaction By letting patients pay at a pace that works for them and their budget, payment plans reduce stress and create a more supportive and compassionate financial experience. When patients know they have options, they're more likely to stay on track with payments and feel more satisfied with their overall care. A major advantage is that these plans can be tailored to each patient's unique situation. For example, with PatientSimple®, patients can use a self-service portal to generate pricing estimates and explore suitable payment plans to make a more informed decision about how they'll pay for care. They can break down bills into smaller and more affordable payments, rather than facing the daunting prospect of a single large bill. Using Experian Health's unmatched data and advanced analytics, PatientSimple offers a richer understanding of each patient's propensity to pay, helping providers make better decisions about the optimal financial pathway for each patient. Patients can access their bills and statements online at any time. This is more convenient for them and frees up staff to give more attention to patients with more complex circumstances. Key benefits of healthcare payment plans for patients and providers Improving the patient experience with healthcare payment plans also translates into financial and operational benefits for providers. Helping patients navigate their financial responsibilities more easily — especially through automation and software-based tools — increases cash flow, reduces admin burdens and boosts overall efficiency. Here are a few examples of how payment plans and other financial tools can benefit patients and providers: 1. Patient Financial Clearance automatically screens patients to determine eligibility for Medicaid or other financial assistance programs. Calculating the optimal payment plan based on the patient's ability to pay gives patients more affordable options and providers more predictable revenue streams. Increasing access to financial assistance also increases access to care, as patients are more likely to follow care plans, leading to better health outcomes. Case study: How UCHealth wrote off $26 million in charity care with Patient Financial Clearance 2. Patient Financial Advisor and Patient Estimates give patients a pre-service, personalized breakdown of what their bill is likely to be, using accurate chargemaster data, payer rates and real-time benefits information. This upfront clarity makes it easier for patients to plan for payments, while providers benefit from fewer payment defaults and improved patient trust. And with fewer bills ending up in accounts receivable, providers can reduce the manual effort needed to manage outstanding balances. 3. Helping patients reduce out-of-pocket expenses is another way to achieve a better financial experience, boosting loyalty and retention. Coverage Discovery® finds any forgotten or overlooked commercial and government coverage, so no costs that should be covered elsewhere fall to the patient. The tool scans for potential coverage from pre-service through the entire accounts receivable file, and automates self-pay scrubbing to detect discrepancies that can be quickly corrected. Accounts that were previously destined for collections, charity or bad debt are instead submitted for payment. Case study: How Luminis Health found $240k in billable coverage each month with Coverage Discovery 4. Finally, removing friction from the payment process will always be a win with patients and providers. Consumers increasingly rely on mobile and contactless payment tools, so it makes sense to offer similar options in healthcare. PaymentSafe® allows providers to collect any payment securely and quickly. Patients can pay anytime and anywhere, while providers benefit from faster, more reliable revenue collection. Maximizing patient experience with effective healthcare payment plans Payment plans aren't just a financial lifeline for patients. They can make or break the whole patient experience. Alex Harwitz, VP of Product, Digital Front Door, at Experian Health, explains the importance of healthcare payment plans and why offering flexible payment options is at the heart of improving the patient experience: “Our most recent State of Patient Access report confirms that many consumers are concerned about how they'll handle their healthcare bills. Having a plan to make costs more manageable can immediately alleviate some of that stress. Providers have an opportunity to step up and help them figure out the best financial pathway.” He says, “At Experian Health, we use data and automated technology to help providers identify patients who need extra assistance and direct them toward appropriate support. Providers that don't offer payment plans, estimates and other financial solutions will struggle to attract and retain patients who can't pay upfront and risk more patient accounts being written off as bad debt.” Paying bills will never be an enjoyable part of the patient journey, but clear and compassionate healthcare payment plans make it easier. With the right technology, providers can simplify and accelerate the collections process, foster patient trust, and most importantly, allow patients to focus on their health instead of their bills. Prescribe the right financial pathway for your patients with Experian Health's industry-leading patient collections technology. Learn more Contact us

Surprise tends to magnify human emotion. If the surprise is positive, a person's reaction to it will be intensely positive. If it's negative, it will be extremely negative. Such is the case with unexpected medical bills, and that's one reason why the No Surprises Act was passed in 2021. It aims to protect consumers from unexpected bills for out-of-network care in both emergency and non-emergency settings. Thanks to the Act, U.S. healthcare organizations must now provide transparent details of the estimated costs of their services – otherwise known as patient estimates. And, so far, it's working. One 2023 survey by Blue Cross Blue Shield and AHIP shows that "The No Surprises Act (NSA) prevented more than 10 million surprise bills in the first nine months of 2023 — continuing to protect millions of Americans from crippling medical bills each year." And as insurance deductibles and out-of-pocket expenses continue to rise, patient estimates are becoming even more critical. Experian Health's State of Patient Access Survey 2024 shows that both patients and providers would like to see improvement in the accuracy of patient estimates. Surveys show that 4 in 10 patients say they spent more on their healthcare than anticipated, and nearly one-quarter received surprise bills after treatment. Creating service transparency takes an effort, but there are also hidden benefits for providers. With medical debt skyrocketing past the $220 billion mark and the cost of care increasing, patient estimates apply much-needed rigor to healthcare billing and collections practices. Why are patient estimates important? Pricing estimates enhance the healthcare experience by making the financial responsibilities of treatment more transparent and more manageable. The benefits for patients include: Understanding potential treatment costs, allowing them to plan and avoid unexpected expenses Making informed decisions about their healthcare options by comparing the costs and benefits of different treatment plans Fostering transparency and trust between healthcare providers and patients Better coordination with insurance providers so they know what will be covered and what will be an out-of-pocket expense Reduced financial anxiety, allowing patients to focus more on their recovery and less on potential financial stress Increased cost awareness and acceptance, prompting them to comply more readily with treatment plans and not cancel appointments Providing a price quote empowers patients while creating a more efficient healthcare system of services rendered and payments received. Why are patient estimates useful prior to treatment? It's better for patients, and the healthcare system as a whole, if patients are more focused on healing and self-care than the stress and anxiety of an unexpected medical bill. If they know what's coming, patients can take control and make plans to alleviate any financial turbulence. In the case of planned care and procedures, pre-treatment cost estimates also allow patients to shop around for the best balance between service and price. In addition to helping patients make smarter treatment choices and financial decisions, patient estimates also help people understand, navigate and coordinate their insurance benefits. That also helps them avoid medical billing surprises that can later lead to collections and damage to their credit scores. How do patient estimates help providers? In today's healthcare landscape, where value and patient experience are key factors in reimbursement, transparency has become crucial in four ways: More satisfied patients: Estimates build trust and patient and provider relationships. This trust is essential for effective communication and patient satisfaction and can help reduce patient churn. Better adherence to treatment plans: Patients aware of the financial implications are more likely to stick to their treatment plans and follow through with necessary procedures and lifestyle changes. Adherence leads to better health outcomes and a more efficient treatment process. Better resource management: Knowing each patient's expected costs and required resources allows providers to allocate and schedule resources more effectively. Improved revenue flow: Pricing estimates at the front end of the medical journey establish upfront financial accountability, which can lead to providers being paid more quickly. As healthcare costs rise, improving price transparency is a win-win for both patients and providers. Patients want clear, upfront information about treatment costs, insurance coverage and payment options so they can plan ahead with confidence. When providers make this process smoother, it benefits everyone—saving time, reducing stress, and making things more efficient. Plus, it can help avoid those tough conversations when patients are caught off guard by unexpected bills. Providing the right information from the start creates a more positive experience for everyone involved. Technology can help create accurate patient estimates Experian Health's Patient Estimates tool makes price transparency and providing accurate estimates easier. This solution leverages real-time data, including insurance coverage, payer contract terms and provider pricing, so that everyone knows exactly where they stand before the service is rendered. Patients can focus on getting well while providers create the accountability they need to get paid promptly. With the right technology, patients and providers can come together in a mutually beneficial and less stressful encounter that leads to better relationships and better health. Contact us to learn how Experian Health can help your healthcare organization empower patients with clear, accurate cost estimates to enhance transparency, build trust and improve overall care satisfaction. Patient Estimates Contact us

The Price Transparency Rule, effective January 1, 2021, requires hospitals to provide clear and accessible pricing information about their items and services online. Although the rule is simple in theory, hospitals are finding it challenging to implement. Under the rule, hospitals can make their pricing information clear and accessible by publishing it online as a comprehensive machine-readable file (MRF) with all items and services and in a display of shoppable services in a consumer-friendly format for at least 300 shoppable services. The Centers for Medicare & Medicaid Services (CMS) states that the rule aims to "help Americans know the cost of a hospital item or service before receiving it." This rule represents a giant stride towards delivering much-needed and long-awaited benefits associated with price transparency. These include empowering consumers to make informed healthcare purchasing decisions based on the costs and benefits involved, enabling cost predictability and closing the information gap between providers and patients. It is also an eye-opener for consumers, preventing them from falling victim to wide price discrepancies prevalent in an opaque pricing system. As Tricia Ibrahim-Zafari, Director of Product Management at Experian Health, states, "The requirements are meant to help patients become true consumers of healthcare." However, the success of the concept of price transparency hinges on hospitals adhering to and implementing the rule. Unfortunately, reports have found that hospitals have struggled with compliance since the rule was enacted. One of the reports, published in February 2024 by the Patient Rights Advocate, found that three years after the Hospital Price Transparency Rule took effect, only 34.5% (689) of the 2,000 U.S. hospital websites analyzed fully complied with the rule's requirements. One of the barriers to the adherence to and successful implementation of this rule is its constant and frequent evolution, making it challenging for hospitals without efficient price transparency solutions to keep up. Stricter penalties due to low compliance rates, increased public access to pricing and the challenging financial environment prohibiting flexible price changes exacerbate existing pressure on hospitals, Ibrahim-Zafari explained. The good news is that hospitals looking to meet the transparency requirements, including the Price Transparency 2024 updates while delivering high-quality care for all, can explore Experian Health and Cleverley & Associates solutions for Price Transparency compliance. These price transparency tools in healthcare help providers comply with the Price Transparency Rule, improve price defensibility and create financial opportunities, as affirmed by Ibrahim-Zafari. Price Transparency 2024 updates: the latest in the price transparency regulatory environment Jamie Cleverley, President of Cleverley & Associates, emphasized that the earlier language of the Price Transparency rule is grounded in provisions of the Affordable Care Act (ACA) and displays noteworthy similarities. Both require making consumer-relevant information easily accessible for easier comparison shopping and providing insights into negotiated rates between clinicians and insurers in a machine-readable format. However, the Price Transparency rule has evolved ever since. Since its introduction in 2021, the Price Transparency Rule has been continuously updated to better align with its intent, to adapt to the changing healthcare landscape and to encourage compliance. For example, Ibrahim-Zafari noted that in 2022, CMS increased the penalty for non-compliance with price transparency requirements from $110,000 to over $2 million a year. Additionally,  the agency imposed stricter timelines for hospitals to address pricing data issues and streamlined the enforcement process. The Price Transparency 2024 updates required to be implemented by hospitals on January 1, 2024, July 1, 2024 and January 1, 2025, fall under five broad categories: new definitions, good faith estimate and machine-readable file (MRF) attestation, ​​standardization of the MRF format and data elements, improving access to hospital MRFs and enhancing enforcement and compliance. Put simply, CMS established definitions for specific terms in regard to the new definitions category. Let's delve into the remaining categories under the price transparency 2024 updates. Good faith estimate and machine-readable file (MRF) attestation The good faith estimate and MRF update emphasize hospital leadership's obligation to verify the MRF content's comprehensiveness and accuracy. Good faith effort - Starting January 1, 2024, CMS requires every hospital to make a good faith effort to ensure that the standard charge information stored in the MRF is accurate and complete. MRF Attestation - Starting July 1, 2024, hospitals must attest to the completeness and accuracy of the applicable standard charge information in their MRF. Cleverley explains that the good faith effort update does not require hospitals to include any attestation on their website or in their machine-readable file. However, beginning July 1, hospitals will be required to use the CMS template for the MRF, which includes an attestation comment, where they must select true or false. Standardization of the MRF format and data elements CMS also introduced updates that ensure the standardization of the MRF formats and data elements across the board. Starting on July 1, 2024, hospitals must format the contents of the MRF into a specific template. This template can be in either .JSON or .CSV format. According to Cleverley, the .JSON format is digital-friendly, making it the preferred option for hospitals. The .CSV format, on the other hand, is more consumer-friendly. Furthermore, the Price Transparency 2024 updates introduced additional required data elements, including five types of standard charges. Some of the new data elements, including "Estimated Allowed Amount," "Drug Unit of Measurement," "Drug Type of Measurement," and "Modifiers," have been stated to be implemented on January 1, 2025. Improving access to hospital MRFs To make hospital MRFs more accessible, CMS requires that from January 1, 2024, hospital websites must include a .txt file in the root folder containing their MRF and contact information. In addition, hospitals are required to include a "footer" at the bottom of their homepage, linking to the webpage that hosts the MRF. Enhancing enforcement Considering that hospitals have been slow to comply with the price transparency requirements, it's not surprising that CMS is ramping up its enforcement efforts through four measures. Increasing scrutiny of hospital compliance efforts - CMS is increasing scrutiny by authorizing comprehensive compliance reviews. Under the Price Transparency 2024 updates, they can also request hospitals to have an authorized official certify the accuracy and completeness of MRF data and submit additional documentation, including payer contracts, to evaluate compliance. Acknowledging warning notices - Hospitals must confirm receiving warning notices from CMS whenever they receive such notice. Addressing system-wide non-compliance - If CMS finds a hospital part of a health system to be non-compliant, they can notify the health system's leadership to address potential defaults from other hospitals within the health system. Publicizing actions and outcomes - CMS noted that it may publish information related to a hospital's compliance assessment, including details about any actions taken and notifications sent to health system leadership. CMS noted that it may publish information related to a hospital's compliance assessment, including details about any actions taken and notifications sent to health system leadership. Experian Health and Cleverley + Associates solutions for price transparency compliance Compliance with the Hospital Price Transparency Rule is indispensable to achieving price transparency. To support providers in adhering to these rules in the best and most efficient way possible, Experian Health and Cleverley & Associates solutions to provide solutions that ensure maximum compliance while improving price defensibility and creating revenue opportunities. Experian Health's Patient Payment Estimates help providers compile a consumer-friendly list of shoppable service items. Cleverley & Associates provides fully compliant and comprehensive machine-readable files for the hospital's "items and services." The price transparency tools in healthcare are available in two options to cater to the specific needs of healthcare organizations: Machine-Readable File - Standard: This solution provides machine-readable files only in the standardized payer-specific negotiated charge format. Machine-Readable File - Premium: This package provides a price transparency machine-readable file and includes consulting services to assist with price changes. Navigating price transparency requirements in the ever-changing healthcare landscape can be daunting. However, the task becomes seamless with solutions from Experian Health and Cleverley & Associates for price transparency compliance. Healthcare organizations can now stay up to date with and meet evolving transparency rules while also improving profitability. Watch the on-demand webinar, featuring experts from Experian Health and Cleverley & Associates, to learn more about the new updates and explore the latest developments and strategies to navigate price transparency in 2024.

Healthcare price transparency is high stakes for both patients and providers. With the average cost of a hospital stay for patients in the United States amounting to $2,883 a day, a patient's bill can quickly add up. Patients need reliable information about the cost of services as early as possible so they can plan accordingly. For providers, transparent pricing helps deliver a more compassionate patient financial experience and reduces the risk of missed revenue opportunities. However, it's also a compliance issue, especially with the introduction of the Hospital Price Transparency Rule. While the Centers for Medicare & Medicaid Services (CMS) found that 70% of hospitals are in compliance as of February 2023, the goal is to reach 100% compliance. Experian Health and Cleverley + Associates have joined forces to address the challenges providers may be facing. Riley Matthews, Lead Product Manager at Experian Health, and Jamie Cleverley, President of Cleverley + Associates, discuss what hospitals need to do to comply with the Hospital Price Transparency Rule. What is hospital price transparency and what is the Hospital Price Transparency Rule? The introduction of CMS price transparency requirements has brought about substantial shifts in the landscape of price disclosure for hospitals across the United States. Enacted as part of the FY19 IPPS Final Rule, these requirements were established in alignment with provisions outlined in the Affordable Care Act. Hospitals are now mandated to provide a comprehensive list of their current standard charges via the Internet in a machine-readable format, with updates required at least annually or more frequently as deemed necessary. This information can be presented in the form of a chargemaster or any other format chosen by the hospital, as long as it meets the criteria of being machine-readable. What are the new price transparency updates coming on July 1, 2024? As of July 1, 2024, CMS mandates that hospitals affirm the completeness and accuracy of their machine-readable file (MRF). This affirmation includes confirming that all applicable standard charge information, as required by § 180.50, has been included in the MRF. Furthermore, hospitals must assert that the encoded information is true, accurate, and up-to-date as of the specified date indicated in the MRF. Also starting on July 1, 2024, CMS will require hospitals to convert the contents of the MRF into a predefined template. This template is available in either .JSON or .CSV format. Additionally, there are new mandatory data elements, supplementing the previously specified ones (e.g., the five types of standard charges). Some of these new data elements have a delayed implementation date of January 1, 2025. What's the difference between the Hospital Price Transparency Rule and the No Surprises Act? The Hospital Price Transparency Rule aims to give patients clear, upfront information about hospital pricing, so they are empowered to make informed choices about their care. The No Surprises Act offers patients protection from surprise billing when they receive certain emergency and non-emergency services from out-of-network providers at in-network facilities. The two sister mandates work together to improve the patient financial experience and help patients navigate their financial obligations. What are the most common price transparency compliance challenges?  Cleverley says there are two main reasons why hospitals may be struggling to comply. First, there is some confusion about what is required to be disclosed (and how). To bridge this gap, Experian Health and Cleverley + Associates have created a standard methodology that satisfies the rule requirements. Second, some providers are hesitant to disclose pay rates amid concerns over financial viability and potential pressure to lower charges. However, the price transparency rule aims to enable market competitiveness and empower patients. Furthermore, making cost estimates freely available improves patient satisfaction by 88%, according to data from PYMNTS and Experian Health. A patient-centered approach to billing and payments not only supports compliance with price transparency regulations, but leads to faster payments and consumer satisfaction. In addition to Patient Estimates and Patient Financial Advisor, which offer patients accurate, pre-service cost estimates, there are a host of other Patient Payment Solutions that allow patients to choose payment plans, manage bills and make payments. How are Experian Health and Cleverley + Associates helping providers comply with the Hospital Price Transparency Rule?  The Hospital Price Transparency Final Rule requires hospitals to display payer-specific rates as a consumer-friendly list of 300 shoppable service items. Experian Health's Self-Service Patient Estimates solution helps providers compile these lists and deliver accurate estimates to patients in a clear and comprehensive way. This puts consumers in the driving seat when it comes to making informed healthcare choices and supports hospitals in providing clear, accurate and legally compliant pricing information. Providers must also make certain pricing information for items and services available as a machine-readable file displayed on their website. Cleverley + Associates has the necessary capabilities to deliver the machine-readable files quickly and at scale. By working together, both organizations deliver a holistic solution to meet price transparency mandates. Jamie Cleverley says this helps hospitals prepare for the changing environment: “It's more than compliance. It’s having trusted partners that are talking through and consulting with hundreds of hospitals across the country.” What is the best approach for providers to ensure price transparency compliance? Riley Matthews says that the first step for providers is to define a strategy that best fits their individual organization. They should identify best practice workflows based on their existing resources and intellectual property and partner with an organization that can bring solutions to areas where the system is lacking. The key is to execute the business strategy while prioritizing the patient experience. Experian Health and Cleverley + Associates can support hospitals in providing an efficient, consumer-friendly workflow, as well as the more robust backend concepts of the machine-readable file. Cleverley says, “We've created a methodology to display aggregated claim payment levels, simplifying the display of information for both hospitals and patients. Many solutions attempt to display just a list of payment rates, but the combination of those lines is really what's most relevant to patients.” For example, a patient coming in for an outpatient surgery has no idea what additional services, drugs and tests they may need. This solution looks at the statistical utilization of services to calculate the charges for that procedure, and then displays that value. This holistic approach meets “not only the letter of the law, but also the spirit of it.” What's next for price transparency? There has been a significant challenge around non-uniformity of data. Hospitals have been using different structures and file formats for displaying required information, but CMS has implemented a standardized file schema for use beginning July 1, 2024.  Cleverley + Associates has a file structure that conforms to the Medicare standard schema and is available to help hospitals understand the new requirements. As the penalties for non-compliance increase, providers need to be proactive in reducing the financial risks associated with price transparency non-compliance. Riley Matthews says that innovation and partnership helps providers get ahead of compliance rules and allows hospitals to focus on patient care. Find out more about how Experian Health and Cleverley + Associates are supporting healthcare organizations comply with the Hospital Price Transparency Rule and improve the patient financial experience.

For many Americans, access to healthcare is increasingly a question of affordability. There's no room for error when it comes to determining a patient's medical bill. Helping patients understand and plan for medical bills starts with calculating patient responsibility quickly and accurately. Incorrect charges, unexpected costs and confusing payment processes create poor financial experiences for patients. According to research by Experian Health and PYMNTS, patients are increasingly worried about their healthcare costs. 46% of those surveyed had canceled care after receiving a high-cost estimate, while 60% of those with out-of-pocket expenses said inaccurate estimates or an unexpected bill would prompt them to consider switching providers. As the stakes get higher, providers must reexamine how to calculate patient responsibility in medical billing so all parties are clear about who will pay for what. Providing that clarity will improve the patient experience, streamline patient collections and protect the organization from bad debt. What is patient responsibility? Responsibility for paying medical bills is apportioned between the patient who receives care, their insurance provider (if they have one), and government payers like Medicare and Medicaid (if the patient is eligible). “Patient responsibility” refers to the portion of the bill that should be paid by the patient themselves. Getting these calculations right is critical to the provider's revenue cycle. Determining patient responsibility starts during patient registration. Here, providers have their first opportunity to check that insurance details are up to date and ensure that the patient has not overlooked any active coverage. If the patient does not have coverage, they'll be liable for the whole bill (or will have to find charity assistance). If they do have insurance, the provider will liaise with their payer to check that the proposed care is covered under the patient's plan and establish any prior authorization requirements. Then, the provider can estimate how much of the cost of care should be reimbursed by the payer, and how much will fall to the patient. The amount paid by patients includes the following categories: Co-payment – this is a fixed, flat fee the patient pays toward their medical care at the time of service. If providers do not have accurate co-pay information available at the time of the visit, they may need to bill or refund the difference later. Not all health plans include co-payments, and those that do often specify exceptions. Deductible – this the total amount the patient must pay toward medical care each year before the payer contributes. For example, if a patient has a $1000 deductible, they must pay the first $1000 of medical bills that year, and any eligible costs on top of that will be covered by their payer or shared between the patient and payer. High-deductible health plans are attractive to patients who don't think they're likely to need care, as these plans often come with lower monthly premiums. However, if the patient does need care, they'll be left footing a greater portion of the bill. Coinsurance – this is the patient's share of remaining medical costs after paying their deductible. Out-of-pocket maximum – some health plans set an annual limit to the amount a patient needs to pay toward care, including co-payments, deductibles and coinsurance. Once that limit is reached, the payer will cover the remaining eligible expenses for the remainder of the period. Clearly, this is a complicated formula. To bill correctly, providers need to know whether the proposed treatment is covered by the patient's plan, how much the payer has agreed to pay for specific services, and whether individual service providers involved in the patient's care are in-network or not. Claims will only be reimbursed if all necessary coding and payer policy requirements have been met. Revenue cycle management tools to calculate patient responsibility Traditionally, providers have relied on teams of hard-working coders and billers to manually compile and review each claim. But with so many moving parts – not to mention frequent payer policy changes and staffing shortages – manual processes are no longer viable. When determining how to calculate patient responsibility in medical billing, providers should turn to automation and digital tools. This can help them augment their staff's capacity to calculate patient responsibility more efficiently and accurately and optimize patient collections. Here are a few examples of how they might do that: Automate insurance eligibility verification - Without understanding exactly what the patient's active coverage includes, providers will remain one step behind in the medical billing and claims management process. Payers are already using automation and artificial intelligence to fulfil their side of the equation, and providers cannot risk being left behind. Automating the verification process allows providers to capture up-to-date eligibility and benefits data, including the patient's co-pay and deductible amounts, to calculate the patient's responsibility pre-services. Find missing and forgotten coverage - As more patients switch health plans, more payers join the Affordable Care Act marketplace, and employer-based insurance changes, it's increasingly likely that the patient may not be 100% sure of their active coverage. With Coverage Discovery, providers can run quick, automated and repeated checks to see if any active coverage has been overlooked. This could drastically reduce the patient's responsibility, leaving them with a more affordable bill. Automate prior authorization - Many health plans require specific services to be authorized by the payer before being administered. Providers must check these requirements pre-service, or face a denied claim which could affect the patient's bill. Obtaining authorization from health plans before administering services can be slow and expensive, and often delays care. The Council for Affordable Quality Healthcare (CAQH) states that automating prior authorizations could save the medical industry $449 million per year (or 11 minutes per transaction). Automated prior authorization software gives providers real-time insights into payer requirements, so they can speed up reimbursement and give patients clarity over what they'll owe. Why use a patient cost estimator? With the necessary insurance information at their digital fingertips, providers can then use a patient responsibility pricer to calculate the patient's co-pays, deductibles and other out-of-pocket expenses. For example, Patient Payment Estimates is a web-based price transparency tool that generates personalized estimates for patients before and at the point of service. Patients get a comprehensive breakdown of what they'll owe, so they can plan for upcoming bills or even pay upfront. Patient liability estimator tools give patients more financial clarity, saving staff time and encouraging prompter payments. They're also an important compliance tool, and are specifically recommended in CMS advice on compliance with the Hospital Price Transparency Final Rule. Accelerate and streamline patient collections Early financial clarity encourages patients to pay sooner. This means it's more likely that those bills are paid in full, instead of lingering on the aged receivables list. In addition to upfront estimates, providers should make the payment process itself as easy as possible. This might include directing patients to payment plans or charity assistance, and connecting patients to convenient payment tools at any point in their healthcare journey. Inevitably, there will be some patients who simply cannot pay their bills. Collections Optimization Manager shows staff which accounts, so they don't waste time chasing the wrong accounts. By scoring and segmenting patient accounts based on the likelihood of payment, and adjusting as the patient's situation changes, Collections Optimization Manager helps providers manage resources more efficiently, while supporting a more compassionate patient financial experience. It also enables more effective use of collections agencies to minimize the cost to collect, and incorporates reporting and benchmarking tools to identify improvement opportunities. Find out how Experian Health's revenue cycle management tools can help providers calculate patient responsibility in medical billing, for a more compassionate patient experience and streamlined collections process.

In today's healthcare landscape, providers face the challenge of making costs transparent and understandable for consumers. The Hospital Price Transparency Rule has driven progress in this area, but there is still work to be done. In 2022, 70% of hospitals complied with the Hospital Price Transparency Rule, up from 21% in 2021, according to the Centers for Medicare & Medicaid Services. The Rule mandates hospitals to provide consumer-friendly pricing displays for more than 300 shoppable services, plus a machine-readable file with rate information. To address this challenge, healthcare organizations need to leverage price transparency solutions that empower patients throughout their financial journey. By equipping patients with advanced knowledge of treatment costs and coverage details, providers can facilitate informed healthcare decisions, expedite payments, foster patient loyalty, and gain a competitive advantage. Prevent confusion about costs with transparent healthcare pricing A recent KFF survey found that almost six in ten insured healthcare consumers have encountered problems paying for care in the last year. More than half said they found it difficult to understand their health insurance, while three in ten said their insurance paid less than expected. Confusion about coverage can lead to delays, denials and difficulties in accessing care. Two scenarios are common when patients are faced with unexpected and increasing healthcare costs: 1) they delay care until their year-end deductibles are met, or 2) they forego care completely. Neither is good for their health, and both can disrupt providers' revenue cycles. By arming patients with advanced knowledge of treatment costs and how these will be split between patients and payers, providers can help patients make informed healthcare decisions without worrying about sticker shock. And price transparency is not just a question of compliance - making healthcare billing more transparent can be a driver for growth, through expedited payments, patient loyalty and market advantage. Compassionate financial counseling, flexible financing programs, clear billing statements and simple payment options all play a role. What can providers do to improve price transparency? Step 1 in delivering price transparency is to ensure compliance with the Hospital Price Transparency Rule. Experian Health and Cleverley + Associates have partnered to help providers satisfy the requirements. Experian Health's Patient Estimates supports providers in compiling the required list of shoppable service items, while Cleverley + Associates delivers the machine-readable files quickly and at scale. Jamie Cleverley, President of Cleverley + Associates, says: “Trying to pull together all of the required information in one place led to a lot of complexity for hospitals, at a time when a lot were short-staffed. We became a natural resource for hospitals. Since we have the information and the technical capacity, we could relieve the anxiety around compliance.” Riley Matthews, Lead Product Manager at Experian Health, says the joint approach has succeeded in helping hospitals comply with both aspects of the rule: “We had a portal that we can integrate with our clients' websites, where patients are able to walk through a user experience that guides them to their price estimates. Cleverley came in with the complex machine-readable files and has been a fantastic partner from the start… We're able to solve both sides of the price transparency rule and provide a holistic solution that delivers value for our clients.” Hear Riley Matthews and Jamie Cleverley discuss how this strategic partnership will help healthcare organizations address the challenges with compliance: Utilizing healthcare price transparency solutions throughout the patient journey To round out the patient financial experience, healthcare organizations should consider proactive solutions that promote clarity and convenience at every financial touchpoint. For example: Patient Financial Advisor is the first solution in the market to provide consumers with a pre-service, mobile-estimated patient responsibility and payment experience. This allows patients to make easy, secure payments as soon as they're ready. Patients get a clear breakdown of everything they need to know about their financial obligations, delivered straight to their mobile devices. To solve for confusion around coverage, Experian Health's Coverage Discovery® solution helps patients find missing or forgotten coverage. Patients welcome their providers' help in identifying additional coverage options, so they aren't billed for costs unnecessarily. Providers can seek reimbursement through those plans, rather than sending accounts to collections. Providers can also promote clarity when it comes to payments. PatientSimple offers patients a secure, 24/7 portal to view and manage their healthcare costs in a straightforward and convenient way. Not only can they see accurate price estimates at the touch of a button, but they can also apply for charity care, set up payment plans, update payer information and make payments to multiple providers. Implementing healthcare price transparency solutions to meet regulatory requirements Creating a more transparent approach to healthcare pricing and billing can be a daunting task in the context of ongoing regulatory change and operational challenges. It's time to incorporate Experian Health's innovative solutions to navigate ongoing regulatory changes, overcome operational challenges, and enhance the financial experience for both providers and patients. Find out more about how Experian Health is helping providers comply with price transparency rules and exceed patient expectations for clear and comprehensive billing experiences.

Proactive price transparency could be a competitive advantage for healthcare providers, as a Kaiser Family Foundation survey suggests a majority of Americans believe Congress should prioritize the issue. The survey revealed that 60% of respondents think legislative action to make healthcare prices more transparent should be a “top priority” for the next Congress, while a further 35% said such laws were “important, but not a top priority.” Concerns about the cost of living are top of mind for many households, with 91% of respondents specifically noting their worries about rising healthcare prices. Providers can help meet the demand for more transparent pricing by implementing solutions to make it easier for patients to understand and plan for upcoming bills. Those that proactively meet and exceed patient demand for clearer pricing information will garner more patient trust and loyalty, and in turn, secure an important competitive advantage in a challenging economic context. Why are patients calling for greater price transparency? For many patients, the process of paying for healthcare is like trying to find their way through a maze, with numerous twists and turns and no clear path forward. Unlike most other purchasing decisions, patients lack upfront information about the options in front of them. Many do not fully understand the cost of care, and as a result, may not be aware of or prepared for the forthcoming financial burden. This lack of transparency causes uncertainty and unease, leading to postponed care or missed payments. With transparent pricing, patients can make more informed decisions and choose the most cost-effective options. Those with high out-of-pocket expenses can shop around for services that best fit their budget and estimate the cost of care in advance. Transparent pricing is especially important for patients with chronic conditions or those who require ongoing care. Are providers meeting the demand for price transparency? Many providers have embraced the push for transparent pricing, by introducing upfront patient estimates and tools to help patients understand and manage their bills. Transparency may be a requirement under the Hospital Price Transparency Final Rule, but providers are also incentivized by the promise of faster payments and fewer time-consuming billing queries. However, implementation of price transparency measures has been patchy: as of August 10, 202, only 16% of hospitals were compliant with the rule. In a podcast interview for Becker’s Hospital Review with Riley Matthews, Lead Product Manager at Experian Health, Jamie Cleverley, President of Cleverley + Associates, suggests two main obstacles: confusion around what information needs to be disclosed (more on this below) concerns that sharing pricing information could negatively affect revenue. The second concern is valid, but evidence suggests that disclosing prices to patients can save money, by reducing unnecessary hospitalizations, readmissions and emergency visits. Missed payments are less likely if patients feel in control of their financial situation. In fact, research by Experian Health and PYMNTS suggests that upfront cost estimates improve patient satisfaction by 88%, which encourages prompter payments. Delivering a better patient experience with accessible pricing information To help healthcare organizations meet patient demands for clearer pricing and ensure compliance with the federal rule, Experian Health and Cleverley + Associates have teamed up to provide a standardized solution. Listen in as Jamie Cleverley, President of Cleverley + Associates, and Riley Matthews, Lead Product Manager at Experian Health, discuss how a new partnership is helping providers comply with the Price Transparency Rule: Each organization brings its specific expertise to help healthcare providers provide clear and compliant pricing information: Experian Health’s Self-Service Patient Estimates tool enables compliance with the requirement to display payer-specific rates as a consumer-friendly list of 300 shoppable items. This tool gives patients upfront, accurate estimates that are easy to understand so that they can make informed choices about their care. Cleverley + Associates helps providers make pricing information available as a machine-readable file, quickly and at scale, so providers can fulfill the requirement to display such files on their website. The solution is neatly packaged to save providers from engaging in discussions with multiple vendors or scrambling to find internal solutions for each individual requirement. Cleverley says that working with the two organizations together can save providers time and stress: “We have the information and the technical capacity to offer a format we think is useful, which complies with all the rules. There’s anxiety around this – providers worry about whether CMS will view [their solutions] as compliant. But with us, they’re working with trusted partners that have had those conversations with CMS, that have released these files already and that have been through the audit process.” For Matthews, this adds up to a user-friendly experience that’s not only compliant but gives patients what they need: “We needed to provide a patient-facing estimate-creating solution that shows those top 300 shoppable services for a hospital or a doctor’s office. We were able to do that through our existing product, Self-Service Patient Estimates. We have this portal that we can integrate with our clients’ websites, which guides patients through the entire process. What we did not have – and where Cleverley came in – were those complex machine-readable files… So, we were able to come in from both sides with price transparency and say, ‘ok, now we solve both, and we’re here to provide a holistic solution.’” From compliance to competitive advantage Penalties for non-compliance with the Price Transparency Rule may have been limited to date, but this may change as the rule reaches its second anniversary. Furthermore, some states are starting to bring in their own legislative measures to protect patients from opaque billing practices. And with patient expectations clearly stated, the pressure on providers to deliver transparency is mounting. But as noted, this is about more than compliance. Patients are looking for a clear and compassionate financial experience and will reward providers that deliver this. Providers should consider how to keep patients informed and empowered at every stage of the financial journey. Experian Health offers a suite of payment tools designed to achieve this, which bring together accurate estimates, tailored payment plan recommendations and convenient payment options. Find out more about Experian Health’s Price Transparency Solutions or watch the video to hear more about Experian Health’s price transparency partnership with Cleverley + Associates.

As household finances tighten, providers face a growing challenge to address patients’ financial needs while caring for their health. A new survey from LendingClub and PYMNTS found that 64% of Americans live paycheck-to-paycheck. That leaves little or no room for healthcare expenses and could mean there’s less in savings to tap as well. Healthcare organizations will need to take extra steps to provide patients with financial support during tough times. Survey results match up with Kaiser Family Foundation data on healthcare affordability. KFF found that 41% of Americans currently carry some form of medical or dental debt: 24% have bills that are past due or that they’re unable to pay 21% are paying providers directly over time 17% owe a bank, collection agency, or other lenders 17% have credit card bills 10% owe a friend or family member “The idea that patients are willing and able to access the healthcare they need regardless of cost is not in line with economic realities,” says Alex Harwitz, Experian Health's VP of Product, Digital Front Door. “But patients and providers may be encouraged to know that there are many digital solutions that can improve access to financial information and provide personalized pathways to meeting healthcare costs, so patients don’t have to go without needed care—or end up with medical debt they can’t manage and the massive stress that goes with it. By helping patients deal with the financial aspect of getting care and offering patient-centric payments, providers can also reduce the need for collections and bad debt.” How does a paycheck-to-paycheck reality affect healthcare and how can providers better support their patients? Here are a few things to consider: 1. There may not be enough money to cover unexpected medical expenses. Roughly half of the adults in the KFF study – including three in ten who do not currently have healthcare debt – are at risk of falling into debt. These respondents say they would be unable to pay a $500 unexpected medical bill without borrowing money. Identifying patients who might need additional information or help is one way providers can offer support. Coverage Discovery finds a patient’s available insurance coverage, including billable commercial insurance that may have been unknown or forgotten, and potential Medicare or Medicaid coverage, so both patients and providers get a clearer picture of what insurance will pay. Patient Financial Clearance is an automated solution that determines which patients are most likely to be able to pay prior to service and which patients might benefit from a payment plan or financial assistance. This solution helps healthcare organizations provide empathetic and supportive financial counseling by allowing staff to connect patients to the assistance programs they qualify for, and can even auto-enroll them. Because Patient Financial Clearance provides this information in real-time, providers can begin a conversation about costs and offer help early in the process when patients can benefit most. 2. Healthcare costs are difficult for patients to gauge. While the average consumer may be able to ballpark the cost of a new car or refrigerator, many can’t accurately predict the cost of a medical or dental procedure. Patients may not know what a complex procedure entails, what the charges for each line item might be, and what insurance will or will not cover. Facing the unknown can trigger anxiety, especially when finances are tight. Increasingly, providers are stepping up with pre-treatment estimates that give patients information about what their expected costs will be—even more so as new regulations require providers to share pricing information with patients and provide detailed cost estimates in advance of service. Patient Estimates is a web-based price transparency tool that generates accurate cost estimates patients can review prior to treatment, to help them understand their anticipated costs and begin planning for payment. 3. Patients who don’t think they can afford healthcare costs may avoid getting treatment. Providing accurate cost estimates is a critical first step, but with so many patients living paycheck to paycheck, estimates alone aren’t always enough. A 2022 survey from Experian Health and PYMNTS found that 60% of patients living paycheck to paycheck with issues paying their bills have canceled a healthcare appointment after receiving a high estimate, as have three in four millennials. “Providing patients with accurate cost estimates in advance of treatment is important to helping them understand and manage healthcare costs,” says Harwitz. “But adding digital tools that can help providers and patients explore their options is an equally important next step. Following through with additional support regarding insurance coverage, payment plans, and financial assistance can help ensure that patients don’t forgo needed care due to financial concerns.” PatientSimple is a self-service portal that allows patients to generate cost estimates, pay their balances using a card on file, set up payment plans, view and update insurance information, and apply for charity care. Behind the scenes, PatientSimple uses advanced analytics and Experian data to identify options for each patient, providing personalized support that can ease the patient's financial journey. Self-service digital tools are the key to providing better support for patients. Self-service tools empower patients to manage their healthcare expenses. Patients living paycheck to paycheck appreciate digital tools that help them work through estimates and bills. Digital tools like PatientSimple and Patient Financial Advisor, which provides mobile access to pre-service estimates and payment options, give patients access to financial information where they’re most likely to use it: on a computer or mobile device. “Solutions like PatientSimple and Patient Financial Advisor use data analytics to create personalized options that take a patient’s insurance coverage and financial situation into account,” says Harwitz. “Patients are not only getting a user-friendly interface, but also powerful support to navigate complex healthcare finances.” Financial health is inseparable from patient health. “The financial challenges facing patients living paycheck to paycheck and the providers working to serve them are increasing,” says Harwitz. “Fortunately, digital tools can provide real support for both patients and providers: pre-treatment estimates, digital access to insurance coverage and billing information, and personalized payment recommendations powered by data analytics. Automated processes mean these additional capabilities are available in real-time and don’t place a massive burden on human resources.” Helping patients mind their financial health is good for providers’ bottom lines: It’s key to maintaining revenue and avoiding costly collections and bad debt. Moreover, supporting patients’ financial well-being is an integral part of providing effective healthcare in the current economy. By recognizing financial realities and improving the patient payment experience, providers can help ensure that financial health enables patient health. Learn more about how Experian Health can help healthcare organizations better support their patients and improve the patient experience.