Patient Price Estimation Market Map: When good faith is a requirement
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In recent years, CMS has taken a more active role in ensuring price transparency for patients. In addition to the 2021 Hospital Price Transparency Rule, CMS also rolled out an implementation of the No Surprises Act, which includes requirements for providers to share Good Faith Estimates (GFEs) with uninsured and self-pay patients for scheduled services. Additionally, payers must share an advanced explanation of benefits with enrollees to help them understand out-of-pocket costs for services.
While the latter implementation is on hold, both of these regulations will require providers to give reasonable estimates for services ahead of time, with a dispute resolution process available for patients charged substantially more than the estimated amount. This creates a new operational and technical challenge for providers looking to comply ahead of broad regulatory enforcement.
The Complexity of Price Estimation
Accurately estimating patient costs is no simple task. Providers must account for variables including:
Payer Contracts: The rates negotiated with each payer can vary significantly, even for the same service. Providers must ensure that these contracted rates are correctly applied when generating estimates.
Service Complexity: Many medical procedures involve multiple services, each with its own associated cost. Bundling these services into a single, accurate estimate requires careful coordination.
Patient-Specific Factors: Insurance coverage, deductibles, co-pays, and out-of-pocket maximums can all impact the final cost to the patient. Providers need to consider these factors to provide an accurate estimate.
Beyond determining a reasonably accurate price, providers also need the infrastructure to enable patients to request good faith estimates and have the information safely delivered to them in a consumable format.
Leveraging Technology for Accurate Estimation
To meet these demands, providers are turning to out-of-the-box price estimation tools that integrate with their existing systems. These tools utilize a combination of MRF transparency data, payer contract details, and payer APIs to generate precise estimates.
Some key features of effective price estimation tools include:
Real-Time Data Integration: The ability to pull in the most current data on payer contracts and patient benefits ensures that estimates reflect the latest information.
Automation of Complex Calculations: Advanced algorithms can automate the bundling of services and application of payer rates, reducing the potential for human error.
Patient-Friendly Communication: Tools that generate easy-to-understand estimates, with clear explanations of what is covered by insurance and what the patient’s out-of-pocket responsibility will be, can enhance patient satisfaction and trust.
Many of these tools, including Careviso SeeQer, Change Clearance Estimator, Clarity Flow, Finthrive Patient Access, PMMC Patient Estimates, PVerify Patient Estimator, and TruBridge Patient Access are packaged into broader patient access products that also include patient eligibility checking and patient payments. Meanwhile, other products like ClaraPrice GFEs, Cleargage Treatment Estimation, Experian Patient Estimates, HealthMe GFE, Rivet Patient Pricing, Turquoise Health Instant GFEs, and Waystar Price Transparency are sold on their own and focus just on solving the patient estimation problem.
The Benefits of Accurate Price Estimation
For providers, the ability to deliver accurate price estimates is not just about regulatory compliance—it’s also a strategic advantage. By offering transparent pricing ahead of time, providers improve the chance that patients move forward with the service, reduce the likelihood of surprise billing disputes, and build a stronger relationship with the patient.
Moreover, accurate estimates can support providers in value-based care models, where cost efficiency and patient outcomes are closely linked. By providing clear cost information upfront, providers can help patients make informed decisions about their care, potentially leading to better health outcomes and lower overall costs.
Looking Ahead: The Future of Price Estimation
Patient price estimation isn’t the sexiest of capabilities, but with patient trust in healthcare at an all-time low, we can expect more regulatory enforcement and the eventuality that patients will get accurate out-of-pocket estimates ahead of every service. While a huge amount of infrastructure for provider-payer communication needs to be built to enable this, we can expect to continue to see more cash and self-pay patients requesting GFEs and testing providers, and those who lean in here will be well-positioned to meet future regulatory hurdles.