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Background: A 2014 patient survey conducted in New York City’s (NYC) STD clinics estimated that 52% of patients were insured. In 2015, enhancements to the STD electronic medical record (EMR) were made to facilitate collection of encounter-based diagnostic and procedure codes, and to collect insurance information and consent for billing among patients aged ≥19 years. Uninsured patients and those unwilling to provide insurance are given a letter describing a sliding scale fee; patients voluntarily submit fees by mail. Before going live with billing insurance companies, a pilot was conducted to assess potential revenue from STD clinic encounters.
Methods: Insurance information and billing codes were transmitted to a revenue management system from STD clinic encounters during a 60 day period (9/1/15-10/30/15) for all patients from whom insurance status was ascertained. Revenue projections for insured encounters were estimated based on reimbursement rates per procedure code, and actual self-pay revenue received was calculated.
Results: Overall, 27.4% (2,674/9,750) encounters to the STD clinics included insurance information; of which, 7.5% (200/2,674) were not billable encounters. Insurance payer type among the remaining 1,419 encounters was: 50.2% (713) Medicaid/Medicaid managed care, 47.9% (679) commercial insurance, and 0.02% (27) Medicare. Maximum potential revenue for these encounters totals $264,404 ($141,976 Medicaid/Medicaid managed care; $117,228 commercial insurance; $5,200 Medicare), but we anticipate being reimbursed for approximately 60% ($158,642) of revenue sought. Actual payments submitted by self-pay patients in this same 60 day period totaled $1,710.
Conclusions: A substantially lower proportion of STD clinic patients provided insurance information than is estimated to have coverage, likely due to confidentiality concerns. While NYC STD clinics are only able to collect viable insurance information for a small proportion of overall clinic encounters and very little revenue is generated from self-pay patients, the potential revenue from billing insurance is substantial, up to $1,000,000 annually.