How to Deal with Patient Responsibility?

As patient responsibility balances climb, practice owners are seeking effective methods of collecting outstanding patient balances and ways to collect more payment at the time of service. Estimating patient responsibility prior to claims adjudication is a tricky business. However, practices can absolutely figure out a payment estimation plan that suits their needs and support the critical task of improving patient collections.

There are a few basic doubts about patient responsibility like:

1. Am I allowed to collect at the time of service when the claim has not been adjudicated?

Practices are having a lot of confusion over whether they’re really allowed to collect the estimated patient responsibility at the time of service. This depends largely on your payer contracts as well as state laws. As more patients are covered by High Deductible Health Plans (HDHP), many payers have become more flexible in allowing the collection of coinsurance and deductibles at the time of service based on the estimated patient responsibility.

However, this often requires that you include the amount paid by the patient on your claim when it is submitted. They also require that you process any refunds for overpayments as soon as the overpayment is identified.

2. How to estimate the exact patient responsibility amount?

Many practices have been creating their own patient responsibility estimates for years, using a spreadsheet and a sample of their most common CPT codes and the associated allowed amounts for their common payers. When you combine this type of tool with your current process of eligibility verification, you can create an estimate for what the patient’s responsibility will be for the visit, allowing you to have a conversation with them about their payment options.

It’s important that your financial policy is up to date to reflect whatever requirements you have regarding payment at the time of service. It is also important that your staff is familiar with those policies and is trained to carry them out.

3. Whether you should collect the full estimated amount?

The additional administrative burden of dealing with overpayments is one of the downsides to collecting the full estimated responsibility at the time of service. Unless the patient has a large deductible that is not even close to being met, you could end up having to refund the patient. You have to be well prepared to monitor your patient accounts for overpayments and issue refunds.

This can happen when a claim from another provider is processed before your claim and there is no longer a deductible owed. There are also patients who have Flexible Spending Accounts (FSA) and Health Savings Accounts (HSA) that may be linked to their insurance payer and are automatically charged to pay for services. You may have seen these adjudicated on EOBs from some of the commercial payers, where the claim will be adjudicated and applied to a deductible on one line and then the next line down you will see another transaction paying the claim from the patient’s HSA or FSA.

To collect the full estimated amount at the time of service, be sure you are familiar with your patients that have an FSA or HSA tied to their insurance. An effective alternative is to arrange permission to put a credit card on file with authorization to charge up to a certain amount automatically directly after adjudication.

Sometimes, practice owners confuse outstanding customer service with assuring patients that “we’ll take care of everything; including billing insurance and assuming financial risk. We have shared a few basic courses of action that will help you to reduce your outstanding patient collections.

  • Managing insurance plan: Many patients have a primary and secondary insurance plan. Patients are solely responsible for managing these two plans. It is up to them to call each plan and let them know if they are a primary plan or a secondary plan. A physician’s office has no jurisdiction to make this differentiation. Since the patient is the owner of the plan, only he can make that phone call.
  • Educating them to read EOB: EOB’s are an insurance company’s way of communicating with a patient. Most patients either throw them away or just don’t understand what they are reading. It is their responsibility to review the EOBs and make sure that the claim processed as it should have. If the EOB shows something different, it is their responsibility to call the insurance company to straighten out the problem.
  • Requesting to pay at the time of service: Request patients pay for co-pays, co-insurance, deductibles, or any other incurred cost before getting any service (You can educate them if required.) It’s a bit of a phenomenon that patients think they can walk in, obtain a service, and not pay for it. You would not be able to go to a restaurant or grocery store and walk out without paying, so why do practices have to suffer a non-payment mindset?
  • Requesting to provide updated insurance info: Those patients who know their insurance plan has changed, but they don’t have the new information yet, so they give you the old information. As the owner of the plan, patients are required to know their insurance information, and if they want you to bill the plan, they must provide accurate information.
  • Blowing your appointments? You have to pay: People just blow off appointments leaving gaps in your schedule, where you could have scheduled a paying customer. Consider assessing a cancellation or no-show fee ( $50 — hurts enough to “remember”), and if the patient does not have a legitimate reason for missing the appointment, send them a bill. Be sure this is clearly written in a cancellation policy that the patient signs at the beginning of treatment. If this is a new patient and you do not have their address, and they have not signed anything, it’s a great opportunity for someone to call the patient. By calling them, you might be able to reschedule that patient.

If you are looking for assistance in shaping up your patient collections process, you can contact us for an initial consultation at 888-357-3226/