Cash Out or Get Paid Back? Unveiling Cashless vs. Reimbursement in Health Insurance

Health insurance – it’s the backbone of American healthcare, but it can also be a complicated task to handle. Two terms you encounter every day are “cashless health insurance” and “reimbursement”. Let’s understand these terms in detail.

What’s the Scoop with Cashless Claims?

Here is how a cashless health insurance claim works: with a cashless health insurance plan, which your patient has, you, the provider, simply send your bill to an insurance company. Then you can receive the payment within 15-20 days from them– and it also means that your patient doesn’t have to pay anything out of their pockets directly.

Why Cashless Health Insurance Claims Might Be Your Best Friend:

• Speedy Payments: Generally, insurance companies do process cashless health insurance claims much faster than payment requests, as far as many providers have personally experienced.
• Less Paperwork: So, after processing, since you do not have to run after your patients with a payment request, you get to focus on providing better care. And that you will appreciate incredibly.
• Happy Patients: Well, naturally; the mere convenience of the cashless health insurance plan notion usually makes patients feel more at ease and comfortable, and, in turn, can make them more likely to perceive necessary medical care as something truly necessary.

The Downside of Cashless Health Insurance Claims:

• Pre-authorization Puzzles: Many cashless health insurance plans mean the insurance company needs to give you the thumbs up, called pre-authorization, before you provide certain services. This extra step can turn out to be a real headache.
• Network Limitations: Your patient’s plan may only cover cashless services at certain hospitals, or with specific doctors that are part of your patient’s insurance company. This can also limit your patient’s choices.
• Payment Delays (Even with Cashless): While cashless health insurance is often quicker, you can still face delays. Claims can get stuck somewhere in the system, leaving you waiting for payment.

Reimbursement Claims: The Old-School Way

Reimbursement claims are essentially a bit more classic reimbursement checks. A patient pays for your services out-of-pocket. They then submit a claim to their insurance company to receive a reimbursement for the money that they have already paid you. By having this type of plan, it allows you some of the following opportunities.

The Upsides of Reimbursement:

• More Patients: Patients with reimbursement plans can generally see any provider they choose, opening you to a large number of potential customers.
• Upfront Payment: You get paid right away by the patient, which is a nice plus.

The Downsides of Reimbursement:

• Delayed Patient Payments & Cash Flow: Unlike cashless health insurance claims, reimbursement often means waiting weeks or even months for insurers to process claims and reimburse patients. This can create unpredictable cash flow and strain your practice’s finances. A dedicated billing agency can streamline this process, ensuring timely and accurate claim submissions.
• Extra Paperwork: At the very least, you or a staff member will need to help your patients fill out claim forms and contact the insurance company to clear up issues.
• Risk of Overwhelming and Errors: Even with dedicated staff, your billing team might face challenges during peak periods or when dealing with complex cases. This can lead to errors, claim denials, and further payment delays. A professional billing agency has the expertise and resources to handle fluctuating workloads and ensure accurate claim submission.
• Collections Burden: Unfortunately, not all patients pay their bills on time. Dealing with collections can be a major headache for healthcare providers, requiring additional resources and potentially damaging patient relationships. A billing agency can handle collections professionally, maintaining positive patient interactions while recovering outstanding payments.

Cashless vs. Reimbursement: What’s Right for You?

First, you may want to focus on cashless health insurance claims, but, as in the previous question, whether or not you should focus on cashless or reimbursement claims is going to depend on a few things:

• Your Patients: What kind of insurance plans do most of your patients have? If they have coverage from an insurer you can work with, that might provide some guidance for your decision.
• Your Specialty: Some specialties might be better suited for cashless health insurance claims than others. For example, if most of your services are elective procedures that are easy to determine in advance, cashless health claims could work well for your practice. On the other hand, if a large part of your workload is spent diagnosing rare illnesses that are difficult to confirm and convince insurers to cover in advance, perhaps reimbursement would be a better bet.
• Your Resources: Do you have a billing services provider who can put together pre-authorization requests, and then follow up on the back end to ensure that insurers pay out on cashless health insurance claims?
• Your Risk Tolerance: Both cashless and reimbursement claims can get delayed or denied, but cashless ones are – in general – more likely to turn out that way. Are you okay with that?

Pre-authorization: The Key to Cashless Success

If you’re choosing to go with solely cashless health insurance claims, pre-authorization is one of the processes you have to master.

• What is it? It’s asking the insurance company beforehand. They will evaluate the request to determine if it’s within the scope of the policy or not.
• Why is it important? Pre-authorization helps health insurance stay affordable through efficient use by only approving necessary treatments.
• How does it work? You have to send a request to the insurance company with details of your patient’s condition and a copy of their health history.

Balancing Act

Most healthcare providers find it beneficial to accept both cashless and reimbursement claims. This gives you flexibility and ensures you can serve a wider range of patients.

Understanding the ins and outs of cashless and reimbursement claims is essential for healthcare providers. By weighing the pros and cons, and by understanding the pre-authorization process, you can make informed decisions that benefit both your practice and your patients.

Make pre-authorizations simple and reduce the number of claims that are denied with Capline’s Pre-authorization Services. Our specialized team will handle all of the obstacles presented when it comes to dealing with insurance requirements and rightfully approving services so that your facility can get paid. Let your staff do what they do best and provide patient care with our pre-authorization services which will relieve them of excessive paperwork and phone work. Partner with Capline’s to ensure that pre-authorizations are effortless and get you the highest percentage of reimbursements possible.