A Guarantee of Payment (GOP) used to assure payment directly to a healthcare provider for covered services. Most international insurers were happy to reach direct billing agreements. Invoices were paid, for the most part, on time and in full. But with an increasing volume of international clients, the gap between care provided and bill paid has lengthened. GOPs are becoming an endangered species, say providers.

Underpaid invoices and reconciliation

Today, there is more invoice rejection – often without notice – and lengthy payment delays for criteria that may not have previously been agreed in the contract but are imposed anyway. In addition, invoices are automatically and consistently underpaid in relation to the copayment or deductible amount collected from the client by the hospital. “This is the cause of more than 60 per cent of underpaid invoices that end up in larger processes of reconciliation,” said Eve S. Jokel, International Patient Services Director at Luz Saúde, one of the largest hospital groups in Portugal with 27 healthcare units and 12 general hospitals. She said: “My sense is that GOPs are progressively offering less and less assurances for the provider to interpret the coverage and count on receiving payment for the medical services provided.”

Danny Quaeyhaegens, Head of the International Insurance Department at Bangkok Hospital Pattaya, agrees. Medical care, he said, proceeds at such a fast pace with admissions that may only take 24 hours. Outpatient visits can be a matter of an hour or less. Yet insurers insist on increasingly stringent and time-consuming processes. He points to insurers that only begin to check pre-existing conditions during this time-limited period. “In our region, the majority of visitors are elderly with often many disclosed and/or not-disclosed pre-existing issues,” he explained. “In other words, time remains a big enemy to obtain a timely GOP.”

Of course, for elective investigations and treatments, the hospital will ask the patient to await the GOP. Others collect payment from the client before they leave the hospital if no GOP has arrived by the time they are discharged. Neither of these options are usually acceptable to patients, however, and hospitals risk upsetting them as a result.

The need to make savings has pushed international insurers to increase case management involvement, set up provider portals and standardise systems for claims processing, say providers. “These changes, in theory, are well intended to support the insurer’s management of their member’s care and service support to regular providers,” said Luz Saúde’s Jokel. Yet there are many unintended consequences.

Insurers now want more information to accompany invoices, and there are times where they delay payments based on these requirements

In her experience, insurers now want more information to accompany invoices, and there are times where they delay payments based on these requirements. This results in more manual work when invoicing international entities. “Sometimes their systems cannot identify all the required information – often co-payment or deductible information we have sent with the invoice and hold payments,” she explained.

Reconciliation processes vary too. Some insurers perform a brief analysis and close the issue with or without agreement, resulting in a potential loss for the hospital. Others open a reconciliation negotiation with the hospital until both sides agree the process is complete, but this takes longer, during which the hospital remains underpaid. “Any amounts not resolved in the reconciliation process end up in the insurer’s favour,” Jokel added. 

Thus, the services hospitals offer – extending credit and providing direct billing to the insurer – are not being recognised as the value-added services they once were, Jokel asserted to ITIJ. Instead, the hospital is coming up against resistance from payers: “More insurers are seeking various methods to achieve payments to be accepted below the invoiced amounts or refer part or all of the bill to be collected from the member,” she said.

Providers including Bangkok Hospital Pattaya say many GOPs are not actually guarantees at all, and may include conditions for providing a payment for a certain service. “We need to be aware of all the small print on those GOPs,” said Quaeyhaegens. “Some companies won’t call their GOP a GOP, but call it an explanation of benefits (EOB) or verification of benefits (VOB).” This approach can make some GOPs unreliable.

Provider portals do encourage providers to manage access and account management. However, providers contacted by ITIJ said these are cumbersome and inconvenient tools that often end up slowing down member access to services and making payments less reliable (reception staff might be asked to manage around 40 portals while a member stands in front of them). Quaeyhaegens said website usability varies so much that additional documentation is often required. “For some companies we consider it sufficient, but for other companies we will still require a formal GOP,” he explained.

This is usually where the portal is too complex, or the companies impose too many exceptions on coverage.

Maria El Khoury, Partnership Manager and Head of the IPMI business unit at the American Hospital of Paris (AHP), said her unit is closely involved with the debt recovery unit in an effort to maintain good customer relations.

Delays of GOPs from payers directly impact the patient

“At the AHP, we have a team that handles GOPs and relationships with partners in order to avoid loss and to make sure patients don’t have to handle the costs,” she said. “Delays of GOPs from payers directly impact the patient, as they will be requested to pay and claim reimbursement from their insurer, so we avoid this type of procedure and limit it to very rare cases.”

As a result, AHP’s biggest challenge is the impact of recent cost containment policies with insurance companies, rather than delays in GOP. Like any other provider, they see financial losses due to non-paid GOPs, mostly from assistance companies or small international insurances. “However, these numbers remain quite low, as we have a whole administrative team working on debt recovery,” she said. 

El Khoury does not see an extension of credit as a viable option. “However, as we are in agreement with the biggest IPMI players on the insurance market, we allow some flexibility when it comes to our preferred partners,” said El Khoury. “Most of our top insurances have flexible payment delays and extensions, as we build a relationship around trust and communication between our teams. In general with these partners, debt is always recovered.”

AHP’s El Khoury believes the best solutions revolve around teamwork and reactivity when it comes to hospitalisations. “No admission is confirmed by the hospital before reception of the GOP according to the cost estimation sent,” she said. And in the case of urgent hospital admissions, she said that if no GOP is received within 48 hours of admission, the patient is informed and is requested to pay and claim reimbursement.

Other solutions suggested by providers include a cash or debit card solution that permits the member to pay for the services. However, the insurer would still be required to confirm eligibility and pricing to prevent fraud. This solution may be impractical for anything beyond simple ambulatory and urgent care situations, said Jokel. Simple instructions on the membership card that allows for ambulatory and urgent care to be provided without a GOP would cut the administrative burden significantly. Authorising ambulatory services, perhaps via an app, might be possible too. 

But radically, Jokel reckons providers should also start to consider themselves more like creditors and apply terms and conditions to manage the credit line more rigorously than they have in the past. That might mean setting a credit limit for each insurer, sending notifications to an insurer when they are approaching their credit limit, and have the ability to act to reduce that limit before additional fees and interest are applied. If the credit limit is reached, their access to direct billing agreements could be suspended. “Providers have to put the onus on the insurer to assist more in controlling the balance in their accounts in the hospitals,” she said. It should not be easy for insurers to delay payments or underpay, she added. Hospitals could also reject case-by-case discounts and discounts over the total amount that is overdue, just to end reconciliation and secure faster payments for the majority of the balance. “Cancelling direct billing with a payer that is not participating in a timely way to resolving their accounts in the hospital is a drastic solution, but one that may sometimes have to be considered if the hospital is not able to implement better controls,” she added.

El Khoury suggests insurers provided proper internal training to their staff to explain different billing and coding techniques. They could also improve the portals. “Debt recovery is quite a challenge for insurers with big accounts, claims pile up and teams tend to miscommunicate. As a provider we end up with having to repeat the same tasks and resend claims over again,” she said. “A solution would be to invest more in their portals, making them fully operational and avoiding back and forth requests.”

Communication and relationship management are key for a successful provider/payer transaction. Dedicating a team or an advocate for a provider would be a great start towards building continuity and trust and avoiding mistakes, she added.

Ultimately, Quaeyhaegens agreed that open, clear and honest communications will solve most problems surrounding delays in GOP. “We want to know what is being checked and why, where in the process we are, what is already done and what is pending and to solve bill settlement problems,” he said. “This is nothing new or innovative or ground-breaking, but normal business manners.”

More specificity is required in GOPs, said Quaeyhaegens: “If we get a GOP for a specialist consultation, is the X-ray/blood test/prescribed medication/nurse assessment included or not?”

Insurers too should have more of an idea of coverage for their customers, ahead of time. “Some insurance companies issue insurance policies (travel and IPMI) without a medical check-up, without pre-existing check upon policy issuance, but then start this due diligence upon the patient's claim,” he said.

But to avoid delays related to GOPs, everybody must play a role. The patient must have the right documents and be willing to fill out forms – consent forms or information release forms, for example.

And hospitals can do better too, he added. They should be able to submit all the documents to the correct insurance/assistance company, including cost information and (English) medical reports, in a timely manner. And for this, they need well-trained staff. “Hospitals need capable and experienced staff to read the insurance portals, GOPs in English, and understand the different wordings and interpretations from different companies and regions,” he said. For that reason, his hospital has a team dedicated to dealing with foreign insurance claims and medical reports, as well as continuous improvement projects and a yearly survey amongst insurance/assistance companies to monitor performance and find aspects that can be improved.

There is clearly work to be done by insurers, assistance companies and healthcare providers

Jokel added that the GOP clarity and payment concerns alone are not the only reason for reduced access to credit from hospitals. Increased costs and reduced human resources for administrative tasks are adding to the burdensome manual claims and reconciliation processes for large debt levels on insurer accounts. “Providers cannot offer unlimited credit, accept ineffective payments timelines, nor dedicate staff to an increasing administrative burden, especially for resolving repetitive reconciliation processes, payment delays, underpayment/no payments, or referral to the member to pay,” she concluded. 

There is clearly work to be done by insurers, assistance companies and healthcare providers to overcome the challenges they all encounter when caring for international patients. But with better communication, transparency of process and the right attitude, many of these issues could be solved.