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Benefits investigations combined with automated tools is a winning combination for patients and providers
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How to Increase Price Transparency in Health Care

Benefits investigations combined with automated tools is a winning combination for patients and providers

Heather Agostinelli is vice president, strategic revenue operations at XIFIN. 


The ability for health care providers to communicate prices associated with their services—for both nonemergency and emergency care—encourages patients to make informed decisions about when and where their care is administered. Unfortunately, standard and accurate price transparency continues to be a challenge even as health care communications become increasingly patient-centric.

The complexities of the US health insurance system make it challenging for health care providers to offer their patients insights around the cost of care. But in addition to routine questions around insurance coverage and patient responsibility when it comes to diagnostic provider costs, surprise billing can cost patients thousands of dollars in out-of-pocket expenses. Moreover, a significant amount of reimbursement has gone unrecouped by clinical labs. 

In January 2022, the No Surprises Act is anticipated to go into effect to support communication around cost of care between patients and care providers, but even with this act in place, price transparency is nearly impossible without active patient involvement and self-advocacy. Fortunately, diagnostic providers have a proven solution for overcoming this issue until, and after, the No Surprises Act is implemented early next year.

Conduct a thorough benefits investigation

A benefits investigation enables a provider to determine benefit design and coverage requirements. It is a smart way for diagnostic providers to start tackling the billing transparency challenge. A strong benefits investigation informs the patient about several claim elements and supports price transparency by:

  • Illustrating the cost of a test and outlining the expected reimbursement at that specific point in time
  • Facilitating understanding of separate deductibles and applicable co-pays for the test
  • Supporting patient-centered lab stewardship and encouraging patient education

As many care environments continue to fluctuate between virtual and physical appointments propelled by the COVID-19 pandemic and interacting with both in-network and out-of-network providers, a clear cost estimation has never been more valuable for both patients and caregivers.

Automation can improve the patient experience

Today, many diagnostic laboratories are integrating automated systems and tools into the benefits investigation process. Automation can help identify and address coverage discrepancies early in the process, so the patient is more likely to receive appropriate details before bills are received, or sometimes even before care is administered. When a lab is faced with information from payers, automation can also help determine the patient’s deductible, how much has already been met, plus coinsurance and co-pay information. Having this level of detail and clarity, especially earlier in the process, provides a clearer sense of patient responsibility and a better patient experience. 

Administrative personnel and lab staff continue to play a crucial role in the process. Instead of spending hours on the phone with insurance providers, automation can free these staff members up to focus on other valuable activities. Often there is missing or unclear information received from ordering providers, and lab staff will need to contact them to remedy these issues. They may also use this time to educate patients. 

As health care organizations prepare for the introduction of the No Surprises Act, running a benefits investigation combined with the adoption and use of automated tools is an effective way to collect relevant financial details that will help patients understand what is and is not covered by insurance. This approach can also improve lab staff efficiency and provide a better patient experience, setting the diagnostic provider up for long-term success.