Hospitals and assistance - working together

Billing concerns

Assistance providers told ITIJ that ongoing issues have affected the financial relationship with hospital providers; billing mistakes, invoicing discrepancies and unnecessary tests have been a real problem said Alerah Turner, Director of Global Provider Networks at World Travel Protection (WTP), a travel risk management company based in Brisbane, Toronto and London. “We’ve seen instances where the patient is charged for five nights even though they were only in the facility for two,” she said. “We’ve also seen multiple ECGs and X-ray exams conducted, which were not necessary or relevant to the patient’s conditions.”

Louise Heywood, General Manager of International Assistance Group (IAG), comprising 160 partners that provide assistance to 200 million tourists, business travellers and drivers per year, said invoices are often received late – months or even years later – causing problems with client insurance companies who cover the claims costs. But often, busy hospitals may delay releasing discharge reports and final invoices for medical care. “This can cause frustration the patient and logistical issues for the assistance team arranging onward transportation,” she said. Getting adequate reports translated into English, the language of assistance providers delays things too. Access to treating doctors can be challenging, especially when working across multiple time zones and when a medical interpreter is required.

Overcharging from hospital providers adds to costs too. “Bills need to be carefully scrutinised to ensure only the tests and interventions requested have been administered and invoiced to control the claims costs on behalf of our insurance clients,” she said. Some underwriters still require physical invoices and receipts. This, she added, can be a problem for some providers who are no longer set up to print and then fax or mail an original invoice or receipt. Many providers cannot accept credit card payments and wire payments can only be processed on weekdays, which adds complexity to managing urgent cases.      

Healthcare inflation affecting providers and payers

Rampant inflation in some countries within South America, for example, can impact medical costs as well as having payment ramifications, she added. For example, legal and banking systems impose high fees or government levies driving up costs. “They can be quite a bit higher than the original invoice and the time investment and paperwork to identify and compensate for the shortfalls or unexpected expenses can be frustrating and complex,” she said.

Today, however, network providers’ rising health costs are having the biggest impact on relationships. And when policy limits do not keep up with the rising cost of medical care, this has significant repercussions, especially if the assistance company is not informed in advance. “Often the patient needs to pay out of pocket to cover the remaining, uncovered cost of their stay which can be significant,” she said. “Hospitals confiscate passports and won’t release them until the bills have been paid.” 

Digitisation could drive efficiencies too if they replace some of the traditional invoicing and payment processes.

WTP’s Turner agreed that the impact of rising costs is significant. “A lot of smaller assistance companies do not have the cash flow to pay large medical bills,” she said. “Waiting for funds from their insurance clients before paying a provider can damage their reputation.” This has a ripple effect on other patients from different insurance companies who also need medical treatment that perhaps underwriters are not aware of.  “We have heard of customers being refused treatment because of outstanding bills from another underwriter who works with the same assistance company.,” she said. “For an industry that aims to save lives, the outcome could be catastrophic.”

Several elements contribute to rising price inflation said Turner; ageing, ongoing treatment costs associated with Covid-19, increased access to mental health support and treatment, increased cost of service driven by higher utilisations rates and CPI increases, and the impact of delayed elective surgeries. “Declining profit margins means increased healthcare costs and the domino effect occurs whereby insurance premiums follow a similar trend,” she explained. Consumers are put off buying insurance, which inevitably means less engagement with global service providers.

US pricing around the world

John Spears, VP Business Development and Marketing at Global Excel Management, a healthcare risk management company, said several institutions are even looking to the US – the most expensive healthcare system in the world – for pricing ‘inspiration’. And within the US cost inflation is being driven further by legislation changes. Take the Health Care Price Transparency Acts, passed in 2021. Hospitals must post a complete list of standard charges online and provide a price estimator tool. “Many of these changes tend to add further technical, administrative, and cost burdens to an already notoriously bureaucratic process,” he added. Today, 85 per cent of hospitals are still not in compliance because several requirements are proving challenging to implement, especially for smaller hospitals which lack the expertise and resources.

Low policy maximums and large policy limitations also complicate matters for providers struggling to take care of their members, respect legislation, and remain financially viable, said Spears. Members, providers, and insurers all expect prompt payment despite the challenges of adapting to legislative changes, policy limitations, and budget concerns. “Having an excellent relationship with providers is key,” he said. “Many will require payment well below their usual standards, particularly when it comes to large medical bills and/or when it comes to foreign patients.”

Spears said he has noticed a growing number of physicians that are no longer maintaining a direct contract with carriers, who are narrowing their networks. “This means that it’s more likely that members, travellers, and expats, will require services from out-of-network (OON) hospitals or physicians or healthcare providers,” he said. Global Excel’s team proactively looks to establish a formal relationship with as many OON providers with established rates as possible, which in turn ensures members can get an appointment.

Building the right network

But managing treatment at a facility that is not part of a preferred network and is unfamiliar with handling international patients – such as some public facilities – can be particularly challenging currently said assistance providers.

With local understanding, the assistance company can assist in both, to manage the local billing requirements and evaluate the cost on behalf of their counterparts in the country where the insurance policy was sold. “This is where local presence and healthcare understanding provided by an assistance company becomes important,” said IAG’s Heyward.

When healthcare providers are working with a new assistance company, providing timely clinical updates, insight into their capabilities, transparency around their billing practices and bank details makes case progression much easier. This builds confidence and means they are more likely to get repeat business from assistance companies too. “For any hospitals looking to get onto the radar of assistance companies, we recommend sharing their cost containment and quality policies,” she said. “We also encourage hospitals to avoid charging large premiums for international patients over local patients, just because they can.” Similarly, Global Excel Management’s network provider team uses a credentialling system that focuses on understanding the strengths of providers and networks.

Revamping existing networks and looking at financial arrangements with clients is imperative.

Billing using International Classification of Disease (ICD) coding system could be helpful going forward too. Today, ICD coding is used from Australia and Brazil to South Africa and Sweden. Yet Thailand, the UK and USA, and private facilities, have their own versions. “It would be a game changer if there was global adoption of the ICD,” said Turner. “For data integrity, healthcare trend analysis and to provide insights into the varying costs associated with healthcare treatments globally, wider adoption of the coding system would alleviate a lot of challenges we see with over-servicing and unbundling of service charges.”

Using technology in healthcare billing

Digitisation could drive efficiencies too if they replace some of the traditional invoicing and payment processes; virtual credit cards with defined payees and specified amounts help to reduce fraud which can be a problem in some countries. “This might be something we can use to replace the guarantee of payment system in the future as well,” explained IAG’s Heywood. “Digitalisation of the guarantee of payment procedure via apps and integration of CMS will provide a frictionless, end to end, customer experience.”

Emerging AI technologies help detect certain patterns that can highlight potentially fraudulent claims from providers too. But Global Excel’s Spears said to manage both the customer experience and the financial components, new innovative assistance models are required – whether in person, virtually or hybrid.  “We try to immediately identify each health need as it occurs, and quickly and safely direct the person in need to the best care for their situation, and then optimize the actual claims process,” he added. “That way we’ll see much lower costs and much happier patients and providers.”

Making it easier for an individual to claim smaller amounts, using a mobile phone through Internet payment systems, such as Google Pay or PayPal, will help enormously, said Ingle. But revamping existing networks and looking at financial arrangements with clients is imperative too. “My recommendation would be that all the companies relook at their network programmes right now,” he said. “Look at who they have in their networks and ask whether they have back-ups,” he said. “Before, a lot of companies said they did but they didn’t really.” For such companies, it’s essential to find another facility that has equal to or similar types of services and the same quality, he said. In addition, Ingle recommends setting up working floats with clients to cushion the effect of large bills and delayed payments going forward. “That's going to be very, very important even though clients will be reluctant to do that,” he concluded.