So you thought collecting from insurance companies was hard? Meet the new payers — your patients.

The average patient is now responsible for paying nearly 35 percent of his own medical bills, more than three times the amount he paid out-of-pocket in 1980, according to the Centers for Medicare and Medicaid Services (CMS). As a result, physician practices are under increasing pressure from patients to offer discounted services and lengthy payment plans, and from insurers to make certain the patients' portions of bills are collected.

In this new world of self-paid healthcare, it's important to have a written financial policy that spells out patients' responsibilities and clarifies the role of staff in collecting payment.

"If a practice wants to get paid, they need to have a financial ... policy," says Elizabeth Woodcock, an Atlanta-based physician practice consultant. "And it's very important that it's written and evenly applied so you don't get patients calling up to say, 'Dr. Joe gave my neighbor a 5 percent discount but he wouldn't give me one.' That's an immediate problem."

The essence of a good policy is to encourage voluntary payment and prevent conflicts with patients, says Charlotte Kohler, RN, a practice consultant in Woodstock, Md. "When you start talking about writing policies, a lot of people say, 'Oh my goodness, it's so big, how do I handle it?'" says Kohler. "I talk about doing them in little chunks, starting with your hot spots, the issues that cause the most conflict or raise the most questions."

Hot spots vary from practice to practice, just as the age and economic status of patients varies by specialty and location. Still, a few universal issues will reliably spark conflict unless they are skillfully handled. These include such questions as whether and how much to charge for missed appointments; which patients qualify for discounted care or a payment plan; and how to terminate a deadbeat patient.

Whether you develop a basic policy that covers only obvious hot spots or a more complete one that tackles every possible scenario, the important thing is to get started. Below are some of the key issues to include in a financial policy.

Put it in writing

Most practice consultants suggest creating a brochure for patients that outlines policies they need to know about, including acceptable insurers and payment procedures (such as when copays are due).

At a new patient's first visit, have a staff member explain the brochure and, ideally, sign a paper indicating that they understand it.

You should also have a more detailed financial policy, in writing, for your staff. There are several good reasons for putting your financial policy on paper. You don't want your billing staff to learn key policies by word-of-mouth —  unwritten policies are often unclear and sometimes employees never hear about them at all.

In the absence of clear direction, some staff members may repeat mistakes they've been making for years, or apply policies they learned at another practice. Some of their actions may even be illegal, since payment collection is a minefield of legal requirements.

Another good reason to have a written policy: practices that accept Medicare or Medicaid are required by federal and state law to be able to document policies affecting these patients. Though it rarely becomes an issue, the law is especially important if the practice offers discounted or charity care.

Finally, a written policy makes a great patient-education tool. Front-office staff can show new patients the policy and underline key points. Doing so informs patients that they are expected to pay their share of coinsurance, or the entire cost of care if they are uninsured. It also gives patients the opportunity to raise questions about financial hardship before they receive care, rather than after the fact, when it's too late to adjust your services to their circumstances.

Be careful, though, not to volunteer the possibility of copay or deductible waivers or any other form of discounted care, warns Jennifer Miller, an attorney in Washington, D.C., for the Medical Group Management Association (MGMA). Advertising discounts is a violation of the federal anti-kickback law, which prohibits practices from giving anything of value in exchange for services covered by Medicare or Medicaid. For this reason, just make sure patients have read your brochure and then refer all questions concerning financial hardship to the business office.