Trends in Healthcare Payments Annual Report 2013

Trends in Healthcare Payments
Fourth Annual Report: 2013
Published: April 2014

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© 2014 InstaMed. All rights reserved.
3 | Executive Summary
4 | Trends in Consumer Payments
6 | Trends in Payer Payments
7 | Provider Sentiment
11 | Payer Sentiment
14 | Consumer Sentiment
16 | Latest Trends and Best Practices
19 | Conclusions
19 | Methodology
19 | About InstaMed
CONTENTS
InstaMed
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Philadelphia, PA 19103
(866) INSTAMED
www.instamed.com
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The surge in HDHP enrollment is causing patients to become consumers of healthcare...

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© 2014 InstaMed. All rights reserved.
EXECUTIVE SUMMARY
The U.S. healthcare payments market is growing at a rapid pace – reaching an estimated $2.7 trillion, as a total of both payer and consumer payments.1 However, administrative costs are estimated to consume 25 to 40 cents of every dollar spent in the healthcare industry.2 These costs are poised to increase as changes due to reform and consumerism reshape the healthcare payments industry at a staggering pace.
Much of the growth in the healthcare payments industry has spurred from the rise in patient responsibility, as the number of patients enrolled in high-deductible health plans (HDHP) increased nationally to 15.5 million as of January 2013.3 Due to this growth in HDHP enrollment, providers are required to collect more money from their patients, but many providers still rely on paper-based, manual payment collection and posting processes. As a result, providers are spending more money and more time to collect from consumers than in other industries, yet still accumulating a large amount of bad debt.
This surge in HDHP enrollment is causing patients to become consumers of healthcare who are sensitive to their healthcare costs. Since the industry is not prepared to meet consumer payment expectations, such as convenient payment methods, consumer dissatisfaction is becoming a growing problem – which negatively affects both providers and payers.
In addition to meeting these consumer demands, payers are also challenged with high administrative costs due to inefficient processes, such as disbursing paper payments to providers. To reduce these costs, many payers are trying to promote adoption of electronic transactions across their provider networks, which, if fully achieved, could result in annual savings of up to $11 billion.4
As patient responsibility continues to increase, providers must collect from their patients more frequently – and often for larger amounts as a result of HDHP enrollment growth.
Payers and providers must work together to meet consumer payment expectations that have evolved through experiences in other industries.
To meet the need to collect more and keep costs low, providers are increasingly offering flexible and automated payment options to patients.
Electronic transactions between payers and providers are increasing as each looks for ways to reduce administrative costs.
KEY POINTS
The 2013 Trends in Healthcare Payments Annual Report demonstrates the business drivers for payers and providers, and the changes they are making to operate efficiently, focus on the consumer and maintain cash flow. This report presents key market trends impacting the healthcare payments industry from an objective view in order to educate the market and promote awareness, change and greater efficiency. This report showcases quantitative data processed on the InstaMed Network and features trends based on qualitative data obtained from healthcare providers, payers and consumers nationwide.

4 © 2014 InstaMed. All rights reserved.
TRENDS IN CONSUMER PAYMENTS
As payer responsibility is decreasing, inversely, consumer payment responsibility, including co-pays, deductibles, co-insurance and balance billing, is increasing. This increasing consumer responsibility means that providers, who previously relied almost solely on payer payments for revenue, are required to bill their patients for more payments owed. Data from the InstaMed Network confirms this trend, as the total number of annual patient payments to providers increased by 72 percent from 2011 to 2013 (Figure 1.1).
Due to the sudden rise in HDHP enrollment, the amount that patients owe their providers for each bill is increasing as well. Out- of-pocket expenses for insured patients are expected to grow from $250 billion in 2009 to $420 billion by 2015.5 Data from the InstaMed Network confirms this trend, as the average dollar amount of each patient payment is growing. In 2011, the average amount of a patient payment to a provider on the InstaMed Network was $110.86, which increased to $133.15 in 2013 (Figure 1.2). This increase, combined with growth in the total number of transactions, demonstrates that consumers not only receive more healthcare bills, but these bills are for larger amounts.
72%
Increase over the
past 3 years
1.1
1.2
$133 in 2013
$120 in 2012
$111 in 2011

In addition to the increase of payment card acceptance in the healthcare industry, more providers are also enabling patients to pay off larger balances over time through payment plans. As a best practice, these plans should enable providers to automatically collect payments on a recurring basis in a compliant and secure way, without the use of multiple paper statements and follow-up phone calls – reducing the time and costs to collect. Data from the InstaMed Network shows that the total number of annual transactions for payment plans increased by 284 percent from 2011 to 2013 (Figure 1.3). This trend is growing rapidly as patients demand ways to easily budget for their growing healthcare costs.
284%
3xmore
or
3 year
increase of
As patient payments represent a growing portion of provider revenue, providers must meet patient payment expectations set by other industries, such as offering convenient payment options and communicating the estimated amount due upfront. Traditionally, providers have received patient payments primarily through paper checks in the mail. Recently, more providers are allowing patients to pay with payment cards over the phone, in the mail or through online portals. Data from the InstaMed Network confirms this trend, as card payments made by patients represented 34 percent of the gross dollar volume of back office payments in 2011, which increased to 42 percent in 2013 (Figure 1.4). This shift in back office payment methods verifies that more providers are accepting payments electronically, and when given the option, patients are willing to pay this way.
1.3
1.4
42% in 2013

As more payers offer ERA/EFT (electronic remittance
advice/electronic funds transfer), more providers
began to accept these transactions to receive
payments faster and improve efficiency with
automated posting and reconciliation. To increase
cost savings, many of these payers try to achieve
more provider adoption of ERA/EFT through
promotional outreach and enabling convenient
registration methods. Data from the InstaMed
Network shows that these efforts have effectively
increased provider adoption of ERA/EFT. In 2011,
payers leveraging the InstaMed Network to promote
ERA/EFT to their providers achieved an average of 44
percent provider adoption based on payer payment
volume disbursed on the InstaMed Network, which
increased to 73 percent in 2013 (Figure 2.1).
TRENDS IN PAYER PAYMENTS
44% 62% 73%
2.1 2011 2012 2013

PROVIDER SENTIMENT
Based on the data surrounding both payer and patient payments, the 2013 industry trends have had a significant
impact on healthcare providers. To better understand the experiences of providers, InstaMed conducted a
nationwide healthcare provider survey. The survey participants ranged from solo practitioners to billion dollar
health systems. The following are the key data points from the survey:
In 2013, 67 percent of providers indicated
that they saw an increase in patient
responsibility.
In 2013, 42 percent of providers said that
they did not know patient responsibility
during the patient visit.
3.1
3.2
In 2013, 76 percent of providers said that it
took more than one month to collect from a
patient.
3.3
Slightly increased
No change
Slightly decreased
67% of providers saw an increase
in patient responsibility
Yes
No
42% of providers were not aware
of patient responsibility during the visit
42%
76% of payments took more
than one month to collect
Less than 1 month
1 - 2 months
2 - 3 months
3 - 4 months
More than 4 months
Don’t know
76%

In 2013, 78 percent of providers indicated
that they typically mailed more than one
paper statement to collect a patient payment.
In 2013, 56 percent of providers answered that their primary revenue cycle concern was related to
patient collections.
3.4
3.5
78% of providers sent multiple
statements to collect
1 statement
2 - 3 statements
More than 3 statements 78%
56% of revenue cycle concern for providers
was related to patient collections
Increase in patient responsibility for payment
Rise in bad debt due to low patient collections
Days in accounts receivable
Contractual payer payment accuracy
Changes associated with healthcare regulations
Rise in operational costs
Other
56%

In 2013, 59 percent of providers said that they collected some amount of money at the point of service for
the majority of their patient visits. When they did not collect at the point of service, 33 percent said that it
was due to uncertainty of the amount due, while 31 percent said that it was due to patient resistance to pay.
When questioned about their various collection methods in 2013, 86 percent of providers said that they
accepted payment cards from patients. However, 94 percent of providers said that they also still collect
paper checks from patients.
3.6
3.7
86%
Paper checks
Cash
Payment cards (e.g., HSA, FSA, credit, debit)
ACH (i.e., directly from the patient’s bank account)
Other
86% of providers accepted
payment cards from patients
59% of providers collected some amount
of money at the point of service
33% of providers did not collect because
they were uncertain about the
amount due at the point of service
I do not accept payment cards
Time consuming
Patient resistance
Uncertainty of amount due
No point of service (e.g., anesthesiologist)
Other
Most of the time
Some of the time
Rarely
Never 59%
33%

In 2013, 76 percent of providers said that
they offered the option of payment plans to
their patients.
In 2013, 93 percent of providers said that they received payer payments via EFT. However, almost all
providers still received paper payments (paper check or virtual card) from some payers, which are not
compliant with the ERA/EFT mandate.
Of the providers that did not receive payer payments electronically, 48 percent said that it was because
payers did not support electronic payments. However, 41 percent of providers responded with “other”
responses, which most prominently were difficulty with payer websites and the inability to receive ERAs
through the provider’s clearinghouse.
3.8
3.9
3.10
EFT
Paper checks
Virtual card
Other
90% of providers still received
paper checks from some payers
90%
76% of providers
offered payment plans
Yes
No
76%
48% of providers did not receive EFT
because it was not supported by the payer
Not supported by payer
Potential for unauthorized withdrawal
Prefer paper checks
Too much paperwork and staff training required
No technology to support it
Other
48%
37% of providers received
virtual cards from some payers

PAYER SENTIMENT
Healthcare payers were also greatly impacted by the healthcare payment trends in 2013. To better understand the
experiences of payers, InstaMed conducted a survey of healthcare payers nationwide. The following are the key
data points from the survey:
In 2013, 50 percent of payers indicated that
they did not currently meet the requirements
for the CAQH CORE Phase III Operating
Rules for ERA/EFT.
Of the payers that offered ERA/EFT to their
providers in 2013, 60 percent indicated that
less than half of their providers accepted
ERA/EFT.
4.1
4.2
60% of payers indicated that the majority
of their providers did not accept ERA/EFT
None
<25%
25 - 50%
50 - 75%
75 - 100% 60%
50% of payers did not
meet the ERA/EFT mandate
Yes
No
Working to meet the
ERA/EFT mandate 50%

When asked for the primary reason why providers did not accept ERA/EFT in 2013, 50 percent of payers
indicated that it was due to a preference for paper checks and/or remittances.
When questioned about their top issue when dealing with their provider networks in 2013, 40 percent of
payers said that it was reconciliation of claim remittances and check/EFT payments.
4.3
4.4
50% of payers indicated that their providers
preferred paper checks and/or remittances
Prefer to receive paper checks and/or remittances
Cannot receive ERA/EFT through their clearinghouse
Lack of provider awareness of ERA/EFT offering
Limited resources to complete required paperwork
Do not have the necessary tools or technology
Other
50%
40% of payers’ top issue with providers
was reconciliation of payments
Reconciliation of claim remittances and check/EFT payments
Claim resubmissions and duplicate claims
Claim adjustments and prior payment reconciliation
Call center volumes
Other 40%

When questioned about their top priority for 2014, 45 percent said that it is technology-based regulations, such as PPACA, CAQH CORE and ICD-10.
In 2013, 75 percent of payers indicated that they leveraged a web portal for member communications.
4.5
4.6
Call center
Web portal
Mail
Email
Other
Text messages
75% of payers leveraged a web
portal for member communications
75%
45% of payers said technology-based
regulations are a top priority for 2014
Rising consumerism in healthcare
IT upgrades and system changes
Other legislative regulations
Analytics and business intelligence
Care management
Cost reduction strategies
Other
45%
Technology-based regulations

CONSUMER SENTIMENT
The 2013 trends data indicates that consumers have become an important constituent in healthcare payments.
With the rise in healthcare consumerism, it is becoming more important to focus on the consumer experience.
To better understand the experiences of consumers, InstaMed conducted a nationwide survey of consumers who
visited a healthcare provider in 2013. The following are key data points from the survey:
In 2013, 72 percent of consumers said
that they did not know their payment
responsibility during a provider visit.
Only two percent of consumers said that they
received their healthcare bills via email in
2013.
5.1
5.2
72% of consumers were unaware
of payment responsibility during a visit
Yes
No
72%
2% of consumers received healthcare bills via email
Mail
Email
2%

When asked how they normally pay their non-healthcare bills, such as utility or cable bills, 55 percent of
consumers said that they paid online and 24 percent said that they paid via their bank’s bill pay portal.
If given the option of various methods to pay their healthcare bills, 79 percent of consumers indicated
that they would pay online through their provider or health plan website, and 49 percent indicated that
they would pay online through their bank’s bill pay portal.
5.3
5.4
Provider or health plan website
Bank’s bill pay portal
Mobile device
Payment plan
Bill pay kiosk in a retail location (e.g., Walmart)
79% of consumers would pay
online through their provider
or health plan website
49% of consumers would pay
through their bank’s bill pay portal
79%
79% of consumers paid
non-healthcare bills online
Online
Payments set up through my bank’s bill pay portal
Mailed a check
79% Credit card over the phone or in the mail

Opportunities for Consumerism
If given the option of various methods to pay their healthcare bills, 79 percent of consumers indicated that they would pay online through their provider or health plan website.
As patient payment responsibility increases, patients are quickly becoming consumers who are sensitive to their healthcare costs. However, the healthcare industry does not successfully set payment expectations with patients or offer flexible payment options, which leaves providers struggling to collect and their patients dissatisfied. To resolve these issues and meet the needs of healthcare consumers, payers and providers must work together to help consumers take control of their healthcare payments – or risk further consumer dissatisfaction and lost revenue.
LATEST TRENDS AND BEST PRACTICES
To learn more, visit:
www.instamed.com/blog/ impacts-of-consumerism-in- the-healthcare-payments- industry
www.instamed.com/blog/ risks-and-opportunities-of- healthcare-consumerism- for-payers
www.instamed.com/blog/ using-smart-big-data-to- transform-the-collection- process
In 2013, 75 percent of payers indicated that they leveraged a web portal for member communications.
The rise of consumerism in the healthcare industry presents unique challenges for payers to improve the member experience. As consumers, members want to manage, pay and understand their healthcare bills in one convenient place. Yet, this expectation has gone widely unmet in healthcare. To address this gap, payers can work with providers to enable their members to simplify their healthcare finances by integrating payment functionality within their member portals. This will ultimately streamline a confusing process to increase member satisfaction.
Discovering Payment Assurance
In 2013, 76 percent of providers said that it took more than one month to collect from a patient.
In today’s healthcare landscape, providers must operate more efficiently to keep administrative costs low and collect more from patients. Many industry experts believe that the recent influx of data and analytics due to innovation in healthcare technology, or Big Data, will give all healthcare organizations the ability to navigate the changes – and ultimately, to thrive. However, to improve efficiency in healthcare, Big Data needs to get smarter. Providers can use Big Data to trigger automated processes and real- time decisions at the staff level in daily operations. Now, that indeed would be Smart Big Data.

78 percent of providers indicated that it takes more than one statement to collect a patient payment.
When you stay at a hotel, are you able to check in without giving your payment card? Of course not. However, consumers receive access to healthcare services with no assurance that they will pay their portion of the bill on time, or at all. As a result, providers send multiple paper statements and even make phone calls to collect payments. And frequently, the payment is written off as bad debt. This is costing providers a lot of money.
72 percent of patients said that they did not know their payment responsibility during a provider visit.
Providers have opportunities to use Smart Big Data and technology to accurately estimate patient responsibility and automatically collect payments, which creates a level of payment assurance already achieved in consumer-focused industries. When providers leverage Smart Big Data to accurately estimate patient responsibility in real-time and automatically collect on that estimate, it becomes functional on a day-to-day basis, enabling providers to efficiently collect payments and thrive in the evolving healthcare industry.
www.instamed.com/blog/ opening-new-channels-to- collect-patient-payments
www.instamed.com/blog/ finding-payment-assurance- in-the-healthcare-industry- with-smart-big-data
Expanding Patient Payment Channels
Nine in 10 providers will utilize a mobile device by next year. Half of providers are considered “digital omnivores” – someone who routinely uses a smartphone, tablet and a computer professionally.6
Smartphones and tablets are quickly becoming commonplace in hospitals and provider offices for clinical purposes, including updating medical records and writing prescriptions. These mobile devices can also be leveraged to collect payments from patients at any location, for instance, when discharging patients in a hospital or during an at-home visit. Furthermore, when using a mobile device, providers gain real-time access to payment information at any time to streamline processes. However, with the high security risks associated with processing sensitive patient and payment data, providers must ensure that they use a tool that is independently certified and accredited to meet the highest regulations for both the healthcare and payment industries.
55 percent of consumers said that they normally paid their non-healthcare bills online, and 24 percent said that they paid these bills via their bank’s bill pay portal.
A growing number of consumers now pay household bills using their bank’s bill pay portal, so they can easily manage all of their bills in one place. By enabling patients to pay their healthcare bills this way, providers reach their patients where they are already accustomed to paying other household bills. This improves the ability to collect patient payments, while simplifying the healthcare payments process for consumers.

In 2013, 76 percent of providers said that they offered the option of payment plans to their patients.
As healthcare providers increasingly rely on patients for revenue, many have started to use more consumer-centered strategies, like payment plans, to collect payments. However, providers will need to implement best practices and policies – including automating payments and communications, and ensuring payment data is secure – to improve processes and efficiency.
Meeting the ERA/EFT Mandate
50 percent of payers indicated that they did not meet the requirements for the CAQH CORE Phase III Operating Rules for supporting ERA/EFT.
While ERA/EFT transactions on the InstaMed Network significantly increased in 2013, many payers are still implementing the technology to meet the ERA/EFT mandate under PPACA. Payers must ensure that they support ERA/EFT in a way that is compliant with the operating rules developed by CAQH CORE. The ERA/EFT mandate requires that payers include the EFT trace number with the remittance to allow easy re-association with the ERA. By accepting these transactions, providers can reconcile payments and remittances automatically, which reduces hours of manual administrative work and the risk of posting errors.
73 percent of all payer payments processed on the InstaMed Network are ERA/EFT payments.
When evaluating how to achieve ERA/EFT, one of the first decisions a payer will make is to “build or buy” – whether to use internal resources to build ERA/ EFT capability or to buy from a third-party vendor. Irrespective of which model a payer follows to achieve compliance with PPACA, there are several key considerations that should be included in the project scope from the beginning:
• Provider Adoption
Reach providers easily to enroll them in ERA/EFT quickly and minimize print and mail costs.
• Financial Controls and Daily Monitoring
Establish dedicated resources and processes to monitor all payment activity on a daily basis, support financial regulatory requirements, protect against fraud when enrolling providers, and support bank account changes and Know Your Customer (KYC) verifications in a timely manner.
• Compliance Requirements
To avoid penalties, identify resources to understand the reform mandate and verify that the payer is compliant.
• Third-Party Relationships
If payers choose to work with a vendor, they need to make sure they know who they are buying from and any downstream, third-party relationships that the vendor may require to deliver a complete solution. It is crucial for a payer to understand all of the relationships in scope, which will help to assess points of failure, risks and the continuity of service for dealing with difficult issues that arise in an electronic processing environment.
www.instamed.com/pdfs/ Implementation-Insights- Models-to-Deliver-EFT-ERA. pdf
www.instamed.com/blog/ key-considerations-for- achieving-eraeft
www.instamed.com/blog/ how-much-is-too-much- best-practices-for-patient- payment-plans

CONCLUSIONS
The data from the 2013 Trends in Healthcare Payments Annual Report demonstrates that the healthcare payments industry is continuing to evolve, and that many providers and payers have already taken steps to accommodate for these changes. In order for all stakeholders to thrive as the industry evolves, they must be aware of how the industry is changing, acutely understand the challenges and apply process and policy changes to prepare. Efficiency, payment best practices, interoperability and security will be crucial to all industry stakeholders as the industry continues to change.
METHODOLOGY
The payer data comes from respondents representing over 3,000 payers nationwide. The group of survey respondents is comprised of 20 percent regional payers; 20 percent national payers; 20 percent third- party administrators (TPA); 5 percent Blue Cross Blue Shield plans and 35 percent other types of payers, including state Medicaid payers and PPOs. The patient data comes from respondents representing over 200 patients nationwide who visited a healthcare provider in 2013.
Sources:
1 IDC Health Insights (2011)
2 NACHA
3 AHIP
4 U.S. Healthcare Efficiency
5 AHIP
6 Epocrates, 2013 Mobile Trends Report
The 2013 Trends in Healthcare Payments Annual Report includes quantitative data from over $85 billion in healthcare payments volume on the InstaMed Network, which powers healthcare and payment transactions for a wide range of providers, from solo practitioners to billion dollar health systems, and payers of all sizes nationwide. The data represented was processed between 2011 and 2013.
In addition, this report includes qualitative market data. The provider sentiment data comes from respondents representing over 100,000 healthcare providers nationwide. The group of respondents is comprised of 69 percent medical practices or clinics; 2 percent durable medical equipment (DME) providers, labs or other offices; 6 percent billing services; 3 percent hospitals, health systems or integrated delivery networks (IDN); and 20 percent other types of providers, including ambulatory surgery centers and physical therapy organizations.
ABOUT INSTAMED
InstaMed simplifies every healthcare clearinghouse and payment transaction for providers and payers, all in one place. InstaMed enables providers to collect more money, get paid faster and reduce the time and costs to collect. InstaMed allows payers to cut settlement and disbursement costs with electronic payments. InstaMed’s single, integrated network simplifies the healthcare payments process for 1,500+ hospitals, 60,000+ practices/clinics and 100+ billing services; connects to 3,000+ payers; and integrates with 50+ practice management systems. InstaMed processes tens of billions in healthcare payments each year at a rate of more than $1,000 per second. Visit InstaMed on the web at www.instamed.com or contact info@instamed.com for more information.

1880 JFK Boulevard, 12th Floor
Philadelphia, PA 19103
(866) INSTAMED
www.instamed.com

Trends in Healthcare Payments Annual Report 2013

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