Health IT, Payers

Tufts Health Plan now supplying real-time co-pay data to providers

This lets physician practices and other care providers collect co-pays at the time of service, eliminating the need to bill for relatively small amounts after the fact and potentially lose revenue.

Tufts Health Plan is now providing real-time feeds to help healthcare providers determine exactly what each patient’s co-payment should be. This lets physician practices in particular collect co-pays at the time of service, eliminating the need to bill for relatively small amounts after the fact and potentially lose revenue.

Tufts Health Plan provides the data in one of two ways, according to Andrew Burke, director of commercial enrollment, billing and benefits for the Watertown, Massachusetts-based insurer. Providers may log in through a Web portal that also allows them to check each patient’s eligibility, or they can send a message to the payer in X12 270 EDI format, as specified by HIPAA transaction standards. The insurance company then returns the eligibility, coverage and co-pay information as a 271 transaction.

The 270/271 option usually is built into practice management software, so Tufts Health Plan does not have to provide custom interfaces for each provider.

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This information is helpful for tiered insurance plans, Burke said, because co-pays can differ even among employees of the same company. For example, the co-pay for visiting a specialist could be $20, $50 or $100, depending on what level of coverage and monthly premium a member chose.

“We found that a lot of providers were unsure and were billing the wrong amount,” Burke said.

Massachusetts has had a price transparency law since 2013. Tufts Health Plan also operates in Rhode Island.

Photo: Flickr user Thomas Hawk