Cigna develops cost-of-care estimator

Cigna plans in April to launch nationwide a tool designed to estimate a patient's cost of care. But during the tool's test phase, some physicians used it to get patients to pay their share of the bill before they walked out the door.

Cigna has tested its "Cost of Care Estimator" at 13 hospitals and with 250 physicians in a 15-month pilot program. The tool works by entering the associated CPT codes into the same physician portal used to determine eligibility. The tool breaks down what the insurer will pay and what it estimates is the patient's portion.

Cigna's intent was to help hospitals provide an accurate and detailed estimate before performing high-cost procedures.

However, "surveys we have done of physicians say this is the biggest benefit to them, as it improves the opportunity to get paid according to what the individual owes. And it improves that dramatically," said Joseph M. Mondy, spokesman for Cigna.

For example, Eagle Family Medicine at Oak Ridge, in North Carolina, has long had a policy of collecting from patients at the time of service, with payments based on estimates that did not include deductibles. The practice said it often collected only 50% of the patient's portion up front, but with Cigna's tool it is possible to get 100%.

The Oak Ridge clinic operates under the umbrella of Eagle Physicians & Associates. Fran Sembert, director of Eagle Business Services, the company's financial arm, said having the deductible information, including how much the patient has met, results in a much more accurate estimate than the practice was able to provide in the past.

"It gives us a comfort level to say, 'Based on what we see in the system today, your co-insurance amount or deductible will be $95.' We feel comfortable collecting $95, and they feel comfortable paying it," Sembert said.

Cindy Dunn, RN , a senior consultant with the Medical Group Management Assn. Health Care Consulting Group, said it should be every practice's goal to collect at the time of service. Tools like Cigna's can make that process easier and more accurate, she said. For practices not collecting at the time of service, the tool could be the impetus to start.

But Cigna members should not be singled out because of the plan's tool, Dunn said. Practice administrators should call other plans to see what tools they offer.

Cigna said its estimator is 90% accurate when compared with the final bill.

Unlike real-time claims adjudication, using the tool does not mean the claim is settled, so its use does come with some risk.

Janet Burton, a billing clerk who is the primary user of the tool at Eagle Family Medicine, said although she has not run into this situation, it is possible the patient could be overcharged, requiring the practice to issue a refund. Or the claim could be denied by the insurer, putting the patient on the hook for the entire amount.

"There's always the possibility the estimate is less than the patient is ultimately responsible for, and the patient will say, 'You said my co-insurance was $100 and it's really $150. Why didn't you say that?' " said Jeffry A. Peters, chair of Chicago-based medical consulting firm Health Directions. The practices need to communicate to the patient, "This is an estimate and might differ, subject to your insurance."

Patrick McDermott, senior vice president of revenue services for Chicago-based Resurrection Health Care, which also participated in the pilot, believes that as more tools such as these are launched and hospitals are able to provide data they can trust to patients, hospitals eventually will catch up with practices in their ability to collect at the time of service.