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Highmark system lets patients know costs upfront

| Wednesday, Dec. 3, 2008

Highmark Inc. has started a claims processing system that can let patients know what their out-of-pocket costs will be as they go for X-rays or other medical services.

The Downtown-based insurer said its new real-time system debuted Nov. 10 and will be available for use by mid-February at 250 hospitals, physicians' offices, imaging firms and other providers. By April, Highmark plans to have real-time claims processing in place at all the care providers it works with in 49 Pennsylvania counties.

While insurers and care providers have provided prices in advance for years, Highmark's system gives more detail.

A Highmark member suffering from wrist pain, for example, who is advised by a family physician to get an X-ray can arrive for the scan, then find out the cost from the provider.

The medical testing center can use Highmark's Web site to estimate within seconds what the patient will pay, and if the test or procedure already has been done, it can submit the claim.

"If the service has been provided, we potentially can at that moment collect out-of-pocket expenses from the patient," said Mary Lou Bradley, business manager for Weinstein Imaging Associates, one of the area's largest imaging firms and one of the first businesses to sign up for Highmark's system. Weinstein has offices in Shadyside, Scott and McCandless.

One health care consultant said the system and similar ones planned by other insurers could give consumers more choices, and perhaps lower patient costs.

"This system shows a patient's liability right up front," said Gerald Katz, a Philadephia-based health care consultant with Kurt Salmon Associates.

"Right now for patients, prices are a crapshoot. You wait six weeks until you get a bill in the mail. Now, a patient could say 'I'll live with that pain a while longer.'"

Robin Bugni, Highmark's Strategic Products director, said the company is "helping our members understand their actual out-of-pocket costs, when they schedule and receive services."

The real-time system primarily is designed to help Highmark members who have opted for high-deductible plans, or have other types of cost-sharing attached to their policies. About 730,000 Highmark members in Pennsylvania are in such plans.

Care providers also like to know up front what amount the patient is likely to have to pay. "Providers want this type of service, so they don't have to chase the member for the fee," said Joe Mondy, assistant vice president of information technology communications for insurer Cigna.

Mondy added that Cigna has been piloting a system for about 18 months that will give payment estimates up front. The system will re rolled out nationally early next year.

The Highmark system also leaves open the possibility of care provider and customer negotiating, should the patient weigh pain versus cost and decide to tough it out.

"Our policy generally says that providers should collect the member's liability, but should a patient back out of treatment, the provider could offer options," Bugni said.

"In the example of the hurting wrist, perhaps the provider would tell the person to ice it or put heat on it, or recommend some other treatment. If the pain became too bad, the X-ray could be rescheduled."

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