Why is it hard to find an app to help patients with medical claims?
“Neither insurance companies nor large healthcare providers are incentivized to save patients’ money,” says Rachael Norman, CEO and co-founder of a new app, – Better – designed to facilitate one aspect of the medical claims process.
How medical claims are filed depends on whether your provider is in-network or out-of-network. Many people erroneously assume that every hospital or provider will automatically file a medical claim with their insurance company.
“If your doctor accepts your insurance then yes, their contract with your insurance company requires that they file the claims for you. Unfortunately, many healthcare providers do not accept insurance and can’t afford to deal with the complexities of submitting claims and making sure that they are paid. This is a growing trend and Americans are spending hundreds of billions of dollars out-of-network each year,” says Rachael.
When this happens, the burden of filing claims, and essentially being a medical biller, falls to the patient. – Rachael Norman of GetBetter.co.
When a provider does not accept insurance, the patient needs to make sure an out-of-network claim is filed.
It can become extremely tricky for patients when they need emergency care. Patients do not have a choice in emergency situations, and emergencies should typically be covered by insurance whether the provider is in-network or out-of-network. However, just because you go to the emergency room, does not mean your visit qualifies as emergency care.
Also, in emergency care, many of the contracted providers, including radiologists, anesthesiologists, and even some doctors, are contractors, and may or may not get the patient’s insurance information from the hospital’s billing department.
Patients are then surprised to find that providers did not automatically file their claims, even though they provided insurance information at the hospital.
The most disturbing piece of this lack of interoperability that befalls the patient is that the person at the bottom of the medical billing or medical insurance customer service totem pole resigns to the fact that the system is broken.
“Unfortunately, it happens. That’s just the way it is!” is often what a patient hears.
Who is responsible to file medical claims for emergency care?
According to Rachael’s co-founder and CTO, John Stockdale, “How these types of claims are handled can vary greatly. Often, the hospital billing department will initially submit the claim to the patient’s insurance but does not follow-up. If the bill contains coding errors, is not classified as an emergency by the patient’s insurance, or is processed incorrectly the hospital simply goes after the patient for the remainder of the bill instead of resolving the underlying issues.”
“Even where there are state laws to protect patients from surprise and balance billing it is often up to the patient to make sure these laws are being complied with. Time and again, we see that when issues arise, it becomes the patient’s responsibility to resolve them,” says John.
“Insurance companies have systems that make it difficult for hospitals and trained billers to get paid back for claims. For many patients, it is too time consuming and complicated to get through. That is why we are here to help!” Rachael explains.
Can the medical claims process be Better?
For out-of-network claims, there is now a Better solution. The Better app’s website says it makes it simple for private pay patients to get reimbursed by their health insurance.
Patients simply take a photo of their bill, and Better does all the work to get patients paid back by their insurance.
In an overburdened administrative system, Better is also a solution for providers who no longer take insurance.
Better’s business model is to charge 10% of the amount patients are reimbursed. Ten percent may be perceived as a small price to pay to be relieved of the hassle. If a claim is applied to the deductible or cannot be covered by insurance, the service is free.
A model for startup success
Better has a very informative blog that outlines some of the pitfalls consumers may come across when it comes to medical claims, including this post on Timely Filing – How Better can get you paid back for old medical bills.
Hospitals and providers have a much shorter time window than patients to file claims. If they do not file timely, the patient can be left holding the bag, even though it is the hospital or provider’s mistake.
Many startups have failed in the medical claims space wrought with complexity. However, Better may succeed because it is not trying to fix all the problems, but is specifically focused on out-of-network care. John adds that Better is funded by “Initialized Capital, Designer Fund, and a wonderful group of angel investors.” To date, Better has raised $1.1M.
Healthtech founders on a mission
Better is also giving back. Rachael tells me Better is committed to erasing $16 million in medical debt for American patients with Better’s initial revenues. The startup was inspired by John Oliver who initiated one of the largest TV giveaways in history by purchasing $15 million in medical debt from collection agencies – relieving many patients of the burden of their medical debt.
I, for one, hope this startup succeeds!
Follow Better on Twitter @BetterClaims.
You can read Part I of this series here: Empowered patient missing in Revenue Cycle Management.
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