Nearly two-thirds of survey respondents also don't now if their providers offer financial resources.

Price transparency protects patients financially, but it can also affect their decision to seek out care in the first place, according to a YouGov survey commissioned by revenue cycle firm AKASA.

The survey of 2,026 Americans between March 9 and March 14, 2022, found that respondents are more discouraged from pursuing necessary care if they are left in the dark about pricing information.

More than a third (35%) said they would be deterred from seeking out care for themselves if they were unaware of pricing, while 40% said they wouldn't be dissuaded and 25% answered they didn't know if it would affect them.

Inaction due to a lack of pricing information was less prevalent when it came to dependents (18.3%) and parents/guardians (20%).

Hospitals have been slow to adhere to the price transparency rule, which went into effect January 1, 2021, but facilities appear to be making progress. A recent report by Turquoise Health found that 76% of hospitals have posted a machine-readable file (MRF), 65% have posted an MRF with negotiated rates, and 63% have posted an MRF with cash rates.

Payers, meanwhile, have generally adapted quicker than hospitals, and the Turquoise Health report found 80 insurers to have published rates.

In addition to price transparency's affect on patients seeking care, the YouGov survey revealed that almost two-thirds of respondents (64%) don't know if their physicians or hospitals offer payment plans or financial assistance for medical bills.

That figure increased significantly for uninsured Americans (80%), indicating that more needs to be done to create awareness and improve the patient financial experience.

"A positive experience is directly tied to an organization's reputation and ratings. It increases utilization, improves loyalty and retention, and, as a result, boosts their bottom line," said Amy Raymond, vice president of revenue cycle operations at AKASA. "Yet improving the patient financial experience in healthcare is one area that continues to lag behind other industries. If the reactive nature of medical billing continues to be the status quo, patients can miss out on opportunities to prevent medical debt which creates unnecessary hardship.

"As hospitals and healthcare systems continue to grapple with slim profit margins, workforce shortages, rising denials, and a high cost-to-collect, they must prioritize the patient financial experience and rethink medical billing and revenue cycle as a front-end, patient advocacy function rather than a reactive, back-end process."

The payer's senior director of business operations speaks on a new pilot program that significantly reduces approval times.

Leveraging automation is a strategy healthcare organizations everywhere are exploring, if they haven't adopted it already.

For Blue Cross Blue Shield of Massachusetts, the benefits of automation are already apparent in their new pilot program designed to streamline prior authorization. The initiative, called FastPass, is piloted at New England Baptist Hospital and successful in speeding up review time, reducing administrative burden, and cutting down on costs.

The technology cross-checks Blue Cross' prior authorization requirements in real-time to determine if approval is needed. When prior authorization isn't required, the provider receives instant notification so they can proceed with scheduling the procedure. When prior authorization is needed, FastPass cross-checks clinical history against Blue Cross' criteria to automatically generate a recommendation. For complex cases, the program automatically packaged the necessary clinical documentation for the clinical review team.

According to Blue Cross, the pilot, focused on hip and knee procedures for 32 orthopedic providers over a four-month span, resulted in 88% prior authorization submissions processing automatically in real-time. Overall, approval time was slashed significantly from an average of nine days to an average of less than one day.

Deb Vona, Blue Cross Blue Shield of Massachusetts senior director of business operations, spoke with HealthLeaders about the payer's vision for FastPass, the importance of reducing prior authorization burden, and how automation can make healthcare organizations' lives easier.

This interview has been edited for clarity and brevity.

HealthLeaders: What factors led Blue Cross to explore this pilot?

Vona: We've been looking at prior authorization innovation for a couple of years. I think it was just the fall of 2020 that we really dug in deeply with our internal innovation team and our IT partners in that 'we need to think of a different way to do this.' We have largely fax and phone based prior process and as we started looking at different vendors and really setting out our goal, one of our key goals from the beginning was we wanted to develop a solution that was truly a win-win-win, as we call it, for all of the stakeholders: ourselves, the provider partners, and our members. Ultimately, there were a lot of solutions that we saw out there that really were just pushing a lot of work to the provider partners. We didn't see that as true innovation.

And as we were scanning the different options in the marketplace, the thing that made Olive stand out from the other vendors and why we launched the proof of concept with them was that they had a system called Pathways that was already installed in some of the provider offices at an orthopedic specialty hospitals in our network. But Pathways give us a small condensed package of really just what we needed so that was already there. And we said that gives all of the advantages that other vendors didn't have.

Pictured: Deb Vona, senior director of business operations, Blue Cross Blue Shield of Massachusetts.

HL: Prior authorization, especially right now from the provider side, is associated with administrative burden and affected by the labor shortage. From the payer side, what makes the investment in streamlining prior authorization worthwhile?

Vona: It's a lot of the same work as on the provider side. We have the exact same recruitment and retention issues today. We have a very high vacancy rate and despite all of our best efforts to fill positions, always have vacancies. So it's to remove that work, particularly remove the work that can be done in a more automated way so that we're really saving those cases that require the human intervention for those people. So there's a lot of it that can be automated. And we know we'll always have nurses, we'll always have doctors, will always have my operations team that needs to handle some of these cases manually. But the value proposition for us is being able to do this in a more affordable way, in a faster way, and see our highly talented, highly expensive clinical team, for those most complex cases, they're not reviewing the cases that are pretty standard.

HL: Why do you see the necessity for automation right now across healthcare organizations?

Vona: I separate this into two things and I think sometimes things get lumped together, but there's automation, which to me is getting our systems to speak to each other. This is all of the information that we need about that member who is going to be scheduled for surgery exists today in that provider's EMR. But without automation what we're doing is printing it out, faxing it over, and somebody on our end is typing it into a different system. The automation part is just how do we get these two systems to connect to each other, to share all that data. It's all exists, it's right there. But we're wasting time by the manual processes that exist. That to me is the first step and the first value add in this process. It's just removing the manual hand off.

Then, where can we use AI once we have that automation to speed up the clinical decision-making components of it? Not every case gets reviewed by a clinician and so that's a narrowing funnel. But the biggest opportunity is the automation piece and getting the systems connected to one another through mobile manual work.

HL: What are Blue Cross and payers in general focusing on to work with providers to make revenue cycle processes more seamless?

Vona: Previously I was on the provider side of operations and financials. I know that this prior authorization and referrals is a big component of that because there's nothing worse than doing the work and then not getting paid because some administrative step was missed. So I think looking at solutions like this to automate that work is a key piece of it.

There's also a lot around trying to give their team a comprehensive view of the different services. And this is where we've been really sensitive to not wanting to develop solutions that would only be Blue Cross-centric. We have heard from the practices loud and clear that 'I'm not just managing this for my Blue Cross members. You're 20% of my business but I have to manage this for all these different health plans.' And that's where I feel like providers are really focused, 'who can pull that all together in one place for my team to be able to manage.' I think that's where we're finding a lot of interest right now.

And again, as we were looking at our solution right from the start, we said we want something that's going to be scalable beyond us. We know that it's in our best interest to try to develop a solution that could be expanded because that's where we can get the best adoption by the provider community.

A new report reveals the top factors members care about when evaluating payers.

Beneficiaries are holding health insurers more accountable and weighing experience factors when considering a switch in plans, according to a report by Accenture.

The benchmark survey compiles responses from almost 11,000 adults between March and May to examine how their insurers perform across nine healthcare consumer touchpoints.

Results show that younger generations are less likely than older adults to consider price, medical benefits, and network coverage to be primary factors when choosing a health plan. Instead, younger generations value experience factors like customer service, convenience, and trust.

The survey finds the top three reasons why beneficiaries leave their payers to be:

1. Ease of navigation (49%) — Respondents identified issues such as inconsistent or inaccurate information, unanswered questions, poor experiences using digital tools, poor customer service, and discomfort with how payers used their personal data.
    
2. Clinical experience/expertise (35%) — Switching factors included prescription drug benefits not meeting needs or expectations, condition management programs not being robust enough to meet needs, and the wellness or supplemental benefits not being strong enough.
    
3. Access/network (32%) — Preferred providers not being in the prior plan network and lack of convenient options were cited as deterrents.
    

To retain members and deliver the experience that is expected, the report highlights four factors payers should focus on: access, ease of doing business, digital engagement, and trust.

For access, more than two-thirds of respondents (69%) strongly agree that insurers that make it easy to find necessary information to select new providers deserve a positive healthcare rating.

"One of payers' primary roles is enabling people to access the quality care they need," the authors of the report state. "People want that to happen with the right information, minimal hassle and flexibility. Payers' effectiveness across these factors has a significant impact on people's perception of their health experiences, and as such, on their likelihood of staying."

Ease of doing business is similarly held in high regard, with respondents being four times more likely to stay with insurers they find are easy to work with compared to those that find their payer difficult.

Digital engagement, meanwhile, is another indicator of loyalty to insurers. The survey finds highly digitally engaged people are more likely to stay (64%) than the national average (55%) and more likely to consider their payer very easy to do business with (74% versus 50%).

Building trust with beneficiaries is essential, which means providing consistent information, helping members understand their coverage, and minimizing hassles. Based on respondents' answers, those who are trusting of their payers are four times more likely to stay than those that are distrusting and almost twice as likely as those who remain neutral.

"Healthcare organizations want to make meaningful progress in responding to people's rapidly evolving health experience expectations," the report states. "After all, loyalty and engagement hang in the balance."

The agency will pay 340B hospitals the average sales price plus 6% for all calendar year 2022 drug claims billed with modifier -JG.

Following the recent ruling on the 340B hospital reimbursement timeline, CMS has disclosed its payment rate to cover 340B drug costs.

CMS will pay 340B hospitals the average sales price plus 6%, instead of the average sales price minus 22.5%, for all calendar year 2022 drug claims billed with modifier -JG (drug or biological acquired with 340b drug pricing program discount), the American Hospital Association (AHA) said.

The payment rate arrives weeks after a judge rejected HHS' plan to wait until January 1, 2023, to restore drug payments to 340B hospitals, instead ordering them to immediately end the cut.

AHA said of the ruling: "We continue to urge the administration to promptly reimburse all the hospitals that were affected by these unlawful cuts in previous years and to ensure the remainder of the hospital field is not penalized for their prior unlawful policy, especially as hospitals and health systems continue to deal with rising costs for supplies, equipment, drugs, and labor."

After the decision, HHS stated on September 30 it would need two weeks to adjust payment rates because it "requires revisions to four different electronic data files and then testing by multiple offices to confirm that the revised files function appropriately before the files are loaded to the production environment where they will be used to calculate OPPS reimbursements on a prospective basis."

With the payment rate now set, CMS said it will reprocess claims Medicare administrator contractors paid on or after September 28 using the default rate.