Matters in Healthcare: Upfront payments for healthcare services

FRIDAY, MAR. 30:

Question 1: Will healthcare providers have to submit claims electronically by August 1?

Answer: No. The Regulations don’t require providers to submit claims electronically.

Question 2: So what exactly happens from August 1?

Answer: Four key things will happen from that date:

• (1) insurers must make eligibility and coverage information available to providers.
• (2) Providers must not charge insured patients for the insured portion of a bill at the time of service.
• (3) Providers will have to submit claims (whether paper or electronic) 30 days from service.
• And (4) Insurers will have to pay electronic claims in 30 days.

Question 3: So from August 1 will I have to pay anything when I go to the doctor or dentist?

Answer: You will still have to pay the “co-payment” if you have insurance. That is the portion of the bill which is not covered by your insurance.

So if your visit costs $150 dollars, and your insurance covers $100, you will still have to pay $50 at the practice.

Question 4: Insurance plans differ a lot; how will my healthcare provider know if I have insurance coverage for services I need?

Answer:  Insurers will have to let providers know who has insurance and for what services as of
August 1.

The new regulations require that this information be made available
electronically and up to date.

Question 5: What do I do if the healthcare provider tries to charge me for the entire cost of the visit?

Answer:  You should inform the Bermuda Health Council (BHeC).

Ideally ask the provider to make the request in writing, or pay the bill if you can and keep the receipt as proof of the upfront payment.

Question 6: If insurance companies don’t reimburse providers within 30 days, what can the provider do?

Answer:  Inform the Bermuda Health Council (BHeC).

Insurers with persistent delays will be fined.

Question 7: Why did Government legislate against upfront charges, when the problem is said to be due to their own health insurers’ delays in payment?

Answer: At the time that more providers started to charge upfront both public and private insurers had long reimbursement times, but that has changed in the past four years.

Currently most claims submitted with all the information needed (i.e. “clean claims”) are paid in less than 30 days by most insurers, including electronic claims to GEHI, HIP and FutureCare.

Delays in payment are caused by claims with incomplete information, and for some insurers paper claims can take longer to pay.

Question 8: Some people say this legislation will increase the cost of healthcare. Will it?

Answer:  Most healthcare providers don’t charge upfront now, and it is unlikely that they have higher costs. So the argument is not completely clear.  Some say that additional administration will mean increased costs, but it is certain that improved efficiency in the health system would actually decrease costs.

Taking the option to submit claims electronically should reduce costs for both insurers and providers, and in the long-run this would mean more cost-efficiency.

Question 9: Can healthcare providers deny me on the basis of the health insurance I have?

Answer:  Yes. At present providers can choose not to take patients from a particular insurer, but few do so.

Most healthcare providers are primarily concerned about patients’ health and don’t discriminate according to insurer.

The new law enables providers to apply for an exemption and will be allowed to charge patients from a particular insurer upfront, if they show that the insurer has failed to pay electronic claims in 30 days.

Get your questions answered

The Bermuda Health Council (BHeC) and the Bermuda Sun have teamed up to answer your questions about the island’s healthcare system.

Visit www.bhec.bm to submit your questions and look for our response the last Friday issue of the Bermuda Sun each month.