Improve Your RCM To Properly Bill Patients Under The ACA

One of the main drivers behind the Affordable Care Act (ACA) was for patients to be able to receive preventative care at little to no cost to them. However, issues have arisen regarding preventative care billing stipulations. According to, most health plans are now obligated to pay for certain preventative services, yet not all types of preventative treatments or tests are covered, resulting in patients still being billed for preventative care.

With hospitals, physician practices and medical centers still working to understand specific aspects of the health care law and preparing for the transition to the enhanced coding system ICD-10, many are struggling with their revenue cycle management and billing patients correctly. USA Today reported on the patient billing issues back in October, but Kaiser Health News recently brought the challenge back into the spotlight.

Patients experience being billed for preventative care
According to Kaiser Health News, one woman received a $1,935 “facility fee” against her $6,000 deductible after she received a preventive colonoscopy, which she had been under the impression would be free due to the ACA.

To right the issue, the hospital’s billing staff resubmitted Rebecca Hyde’s bill with a different billing code to improve the chances that her insurance company would foot the majority of the cost. By offering to recode the procedure, the hospital improved its chances of maintaining high patient satisfaction. However, patient billing issues will only continue. Under the traditional fee-for-service billing system, hospitals use separate codes for the various aspects of the procedure. Kaiser noted that hospital’s RCM and billing processes are having troubles adjusting to the ACA, which does not provide clarity on which aspects of preventative care hospitals can bill.

The ACA has, without a doubt, faced opposition from day one, but the preventative care billing issue among hospitals continues to a key challenge. For consumers, health care reform was supposed to make it more affordable for consumers to receive the care they need to stay healthy, but such large bills make it seem as if the ACA is not benefiting them.

“I thought it was the bait-and-switch: They tell you it’s going to be preventive and then you get a really large bill,” Hyde told Kaiser about when she received her statement.

A National Public Radio blog suggested the Department of Health and Human Services has started creating guidance on ACA preventative care provisions to prevent this issue from continuing.

“We continue to monitor how the preventive services provisions are being carried out, and we are working with stakeholders to ensure they understand our guidance and to offer further clarity to them when needed,” said Joanne Peters, spokeswoman for the HHS, according to NPR.

Hospitals need to create optimized RCM plans for patient billing
While Kaiser reported Hyde’s billing issue has yet to be fully resolved, it brings up the issue that seems to be plaguing hospitals across the country: what can health systems do on their own to alleviate the issue? Until the HHS develops official guidance, hospitals will continue to encounter billing issues and have issues collecting from patients who received high medical bills for preventative services. This can cause patient satisfaction to suffer and result in ongoing RCM issues.

Hospital executives need to consider their options, the best of which is providing patients with clear bills through patient friendly billing. Not only can such technology help patients better understand how much they owe but it can also facilitate timely payments through convenience. Patients may still have to appeal to their health plans and insurers, but optimizing the hospital’s RCM system and improving patient billing can significantly impact patients’ satisfaction with the health system.