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Don't Know How Much an X-Ray Costs You? Highmark Network Providers Will Begin Having Conversations With Highmark Members About Their Actual Cost of Care

Real-time capabilities support providers in discussing health care costs

PITTSBURGH, Dec. 1 /PRNewswire/ -- As health care costs continue to rise, many employers have shifted more of the cost of health care to their employees through higher premiums or cost-sharing on their benefit programs with deductibles and coinsurance. To help consumers better understand their actual cost of health care, Highmark providers, such as primary care physicians, specialists, health care facilities and hospitals, now have tools to assist them in discussions with Highmark members about their out-of-pocket costs. Highmark is the first insurer in the region to roll out real-time capabilities, which gives providers the ability to set payment expectations with members. With real-time capabilities, providers can send an electronic claim to Highmark and receive a response indicating the amount the Highmark member owes. Providers can use these tools prior to service or at the point of service, and then have the option to collect this payment or make payment arrangements with the member at the time services are received.

For example, if a Highmark member were scheduled to receive an x-ray, the provider could use Highmark's real-time capabilities to estimate the cost of the x-ray to the member taking in to account their specific health benefit design including deductibles and coinsurance. The member would then have a clear understanding of their financial responsibility for the service and would be prepared to make any necessary payments to the provider.

These real-time capabilities allow Highmark members with high deductibles, coinsurance or other types of cost-sharing to better understand the actual cost of health care services. Approximately 730,000 Highmark members in Pennsylvania are currently enrolled in health plans with cost-sharing that includes deductibles and/or coinsurance for in-network services.

"Over the last few years, we have seen continued growth in cost-sharing health plans such as those with high deductibles or coinsurance," said Robin Bugni, Highmark director of Strategic Products. "To help our members become true 'consumers of health care,' Highmark is taking the next step in the evolution of consumerism by helping our members to understand their actual out-of-pocket health care costs when they schedule and receive health care services. With Highmark's new real-time capabilities, providers can discuss these costs with patients and make payment arrangements at the time care is delivered."

Highmark's real-time capabilities give providers two unique tools: Real-Time Provider Estimation and Real-Time Claims Processing. Real-Time Provider Estimation allows the provider to submit requests for specific health care services -- before a member receives care or at the time of service -- and estimate the member's financial responsibility within seconds. This, in turn, can be utilized to address the member's desire to know the cost prior to receiving services, and collect or make arrangements for payment at the time care is delivered. Real-Time Claims Processing gives providers the added ability to submit claims for specific health care services and receive a fully processed claim response within seconds. This, in turn, enables the provider to collect or arrange for payment of the member's share of the cost at the time service is provided.

The costs to a member are calculated based upon the members' specific health plan taking into consideration their copayments, coinsurance, deductibles and other benefit structures.

Some 250 providers across Highmark's service area will begin using the real-time tools during the initial roll-out period, which started in November. In April 2009, all Highmark providers with access to Highmark's provider portal will be able to use the real-time capabilities.

"Without tools like our real-time capabilities, it's difficult for providers to give accurate information to members about what the cost of a health care service will be," said Bugni. "Some providers are trying to estimate what the member will owe without a claim processing against their benefit plan. Real-time capabilities from Highmark will give our members the added assurance that the information has been calculated using their benefits and their claims payment history for that year."

Real-time tools also have an administrative benefit for providers as they will allow providers to avoid billing, collecting payment after the patient leaves or writing off unpaid balances.

"We know that on average providers collect 50 percent of patient financial liability," said Bugni. "Providers who use Highmark's real-time capabilities will be able to set clear payment expectations with the member prior to or at the point-of-service and better collect the members' deductible and coinsurance costs."

About Highmark Inc.

As one of the leading health insurers in Pennsylvania, Highmark Inc.'s mission is to provide access to affordable, quality health care enabling individuals to live longer, healthier lives. Based in Pittsburgh, Highmark serves 4.6 million people through the company's health care benefits business. Highmark contributes millions of dollars to help keep quality health care programs affordable and to support community-based programs that work to improve people's health. Highmark exerts an enormous economic impact throughout Pennsylvania. A recent study states that Highmark's positive impact exceeded $2.5 billion. The company provides the resources to give its members a greater hand in their health.

Highmark Inc. is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. For more information, visit

SOURCE Highmark Inc.
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