Full insurance coverage for COVID treatment is expiring. How will providers adapt?

The health care industry hasn’t fully adapted to treating patients as consumers the way other industries have.

Americans owe an estimated $60 billion to $125 billion in COVID-related medical debt, and experts believe that overwhelming number is only going to grow. And yet too often, for all kinds of reasons, health insurance coverage for medical procedures goes undetected by patients and providers alike, leaving both at financial risk. In 2020 alone, Experian Health found “hidden” health insurance coverage associated with $13.4 billion in charges for more than 2,000 healthcare entities.

In an attempt to address this problem, the government stepped in to provide health insurance subsidies for unemployed Americans at the start of the pandemic, when millions lost health insurance coverage and most major health insurers voluntarily waived costs associated with a COVID treatment. But certain benefits, along with the health plan waivers, are expiring, and both patients and healthcare providers are concerned about what that means for their ability to afford the care patients need and providers took an oath to deliver.

With temporary measures that were put in place during the pandemic expiring, it’s difficult for providers to know which patients are covered for what service. But why have unknown or hidden health insurance coverage caused problems since long before COVID?

There are a lot of reasons, but let’s unpack a few of them for the sake of example:

  1. Patients may have health insurance that’s “unknown” to the provider because:
  1. Patients may be unable to communicate to their provider because of an injury in an emergency department setting.
  2. Patients may not know they have insurance if they are covered by Medicaid or included in a spouse’s or parent’s insurance plan.
  3. Patients may not have their insurance information at the time of their visit, and their patient profile isn’t updated before the bill is sent.
  4. An error in the scheduling and registration process. Sometimes insurance coverage returns as invalid due to a typo or another mistake.
  1. Other times, there may be “hidden” health insurance coverage that health care providers simply are unaware of, such as:
    1. Patients with high-deductible plans who try to avoid paying against their deductible by not disclosing coverage.
    2. An update to the insurance policy after the patient’s appointment, or if the insurer allows retroactive billing.

Uncovering and applying existing coverage, whether it is Medicare, Medicaid or commercial insurance, can be a game-changer for all parties in the health care industry. If a hospital doesn’t discover a patient’s health insurance coverage until significant time has elapsed since the service was delivered, it could miss the authorization or notice of admit requirements, resulting in a reduction of payment or a complete denial from the insurance carrier. This is a serious issue, considering that Experian Health’s 2021 State of Patient Access survey found that roughly 70% of providers experienced a revenue shortfall during the pandemic.

Discovering and applying insurance coverage also hugely affects the patient experience. There is significant patient abrasion when a patient expects their insurance to cover a medical service but then they are billed for it. Using existing coverage also helps eliminate bad debt write-offs, reduce accounts receivable days and decrease unneeded charity designations.

Challenges also arise when patients receive a bill that is either higher than the estimate provided or simply more than they were expecting. Some patients won’t even make a necessary doctor’s appointment if they believe they can’t afford the service. According to the State of Patient Access survey, nine in 10 health care providers agree that accurate estimates will help with on-time payments, and that lack of insight into a consumer’s insurance coverage has created increased concerns about collecting payments.

Additionally, health care providers are preparing for the changes to come with the implementation of the No Surprises Act, which protects patients from surprise medical bills related to emergency medical services. When patients don’t have coverage, they often can’t pay, meaning patients are stuck in a troubling position, and providers don’t get compensated. So how can providers and the health care system as a whole address this issue?

The pandemic has spurred significant advances in the use of technology and digital tools related to the patient experience and patient identity, but there’s still a lot of room for growth. The health care industry hasn’t fully adapted to treating patients as consumers the way other industries have.

The good news is, a lot of great progress is being made. Data and technology are leading to more seamless, reliable solutions for patients and providers alike, from scheduling to price transparency to uncovering insurance not initially captured to accepting payments and offering payment plans. As full coverage for COVID-related treatment winds down, providers don’t have to go it alone or go unpaid, and patients likely have more medical insurance coverage than they realize.

There's no better time than now to positively impact the bottom line and the patient experience with technology that finds missed coverage, ensuring patients receive the treatment they need, and providers receive the reimbursement they deserve.

Jason Considine is chief business development officer at Experian Health.