Apply Out-of-Pocket Health Costs to Deductibles in One Click

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Trend Toward High Deductible Health Plan Options

My wife and I, like 17.4M other Americans, are on a high deductible medical plan with a Health Savings Account (HSA) option. A few years ago, we switched to an Aetna Individual Advantage Plan because it provides us with lower monthly premiums. In exchange for those lower monthly premiums, we're responsible for paying for our healthcare until we've met the deductible.

Sticker Shock on Lab Tests

When we first switched to the high deductible plan, a health care provider asked my wife to have some blood tests performed in the lab that was part of their facility. To our shock, we received a bill for several hundred dollars after the fact, even with the "in-network insurance discount." Later, she found out the same tests were available down the street for 10% of the cost, if paid in cash.  Now we make a practice of shopping around for the best prices before any procedure or lab test. PokitDok's Quote Request feature is especially useful for inquiring about prices in your area.

Growing Demand for Paperless Application Towards Deductible

In September, I attended the Health 2.0 Conference with other members of the PokitDok team. A lot of folks at our booth inquired about the PokitDok Platform APIs and the ability to submit cash payments directly to insurance companies and have them applied directly to the deductible. The PokitDok Platform API for claims supports a "patient paid amount" as a convenience for consumers that paid cash and wish to also report the information to their insurance company so that it may contribute toward their high deductible.

Getting the Best Value for Annual Well Exam

After returning from the conference, a healthcare provider requested that I have some blood work done. It was also time for me to have my annual physical. (Since moving to the high deductible plan, I've been trying to have a full physical each year for preventative reasons). I've found that Palmetto Proactive Healthcare offers the best value in my area for these services, so I typically stop by one of their offices about this time each year to take advantage of the Stay Well Special.

Since they also offer some of the best prices on lab work in the area, I got the requested blood work done along with this year's Stay Well Special.   While Direct Primary Care practices like Palmetto Proactive do not contract with outside parties, they will provide full encounter information at the end of each visit so that it can be submitted for insurance processing if the consumer wishes, a typically laborious and paper-intensive process with non-transparent, unpredictable and delayed outcomes.

What if it Were as Easy as One Click?

Let's consider my recent encounter to illustrate how healthcare providers might use the claims API for cash paying customers that wish to have their payments contributed toward their deductible. When a health care provider generates a receipt indicating the services were provided and been paid for, it's translated to the following PokitDok Platform claims API call:

Each claims API request can be tracked with the activities API to allow applications to track claims processing. The claims status API may also be used to track the claim data as it moves through the adjudication process.

With the claim now completely processed, a call to the claims status API shows that the claim processing has been finalized. Insurance does not need to pay since the consumer paid at time of service and the consumer has not met the deductible. The claim status response also indicates that the claim has contributed toward the deductible (applied_to_deductible is true).

Claims status API request:

Claims status API response:

The claim is also visible via Aetna's member web site:

completed_claim_listed_aetna_member_site

completed_claim_part_one

completed_claim_part_two

Using the eligibility API, we can now see that a portion of the claim has indeed contributed toward the deductible, freeing me from the hassle of doing it myself. If I had purchased the well visit in advance through PokitDok's Marketplace, it would have been a one-click transaction. Since I'm in good health this year, this was the first amount to be contributed toward my individual deductible.

Here's my updated deductible summary within an Eligibility API response:

You can see that $123.96 of my recent visit has been contributed toward my individual out-of-network deductible.

In Summary

APIs such as claims, claim status and eligibility allow healthcare providers to focus on providing quality care at fair prices while still offering modern experiences and interfaces to payers. The translation to the consumer is a one-click transaction and better overall healthcare experience.

About Brian Corbin

Brian Corbin is Engineer #1 at PokitDok. He's currently focused on making complex transactions as simple as possible via modern APIs.

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