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HSAy What?!


Like it or not, health savings accounts are becoming more prevalent in today's medical environment.

Like it or not, health savings accounts are becoming more prevalent in today’s medical environment. An HSA is a low-premium/high-deductible plan where the patient pays greater out-of-pocket costs than he would under a more traditional plan. Medical practices are becoming concerned about how to successfully collect patient copays prior to the office visit and also how to ensure that their patients comply with recommended follow-ups.

For example: A patient visits your practice and is charged $73 prior to seeing the doctor for a routine visit. Later, that same patient receives a bill from your office for an additional $35. He’s understandably annoyed and wonders why he’s being charged more money. Isn’t $73 enough? The explanation is simple from your viewpoint: The level of service generated by the visit turned out to be greater than initially expected. This scenario usually ends with the patient calling your office and refusing to pay the additional $35 because he feels that his visit has already been paid for, and he has a receipt to prove it!

A further complication might be that this patient was also scheduled for an MRI as a follow-up to his office visit. Because of his high deductible, the patient informs your scheduler that he will have to delay the test until he can afford it. In good conscience, how comfortable are you with your patient’s decision to delay treatment? Ethically, what is your responsibility for ensuring that your patient be tested in a timely manner?

Here are my suggestions for addressing these two separate issues:

First, how do you justify the need to be paid additional funds when you initially collected for the visit at check-in?

  • Refer to the fee schedule for this patient’s insurance carrier. You are contractually authorized to collect a payer’s allowable amount, but you’re also contractually limited to collecting only the allowed amount, regardless of your billed charge, from your patients.



  • Use calm, polite reasoning. Attempt to explain to your patient the reason for the increased charge and ask politely for the additional payment.



  • Communicate your HSA payment policies. Have your staffers inform your HSA patients that full payment is expected upfront, based on expected insurance reimbursement, but that occasionally they may be charged subsequent fees, depending on the ultimate level of service and any additional procedures performed.

In the case of the irate patient, it might be a good idea to write off the balance due, chalking it up to a lesson learned. Resolve to make sure in the future that HSA patients understand such financial ambiguities.


Frankly, you should make sure all your patients understand your payment policies. If your procedure is to collect copays prior to the patient visit, then make that clearly apparent to your patients by prominently posting a payment policy at the front desk.

Second, do you have a legal responsibility to and/or a quality-of-care problem with the patient who excessively delays treatment for financial or personal reasons? Since you have already established a physician/patient relationship with this patient and ordered a test based on medical necessity, I do think you are under legal obligation to make a reasonable effort at follow up. That said, “You can lead a horse to water….”

Therefore, document, document, document! Keep a log of patient referrals -- electronically or the old-fashioned way -- and review them on a routine basis. Assuming that the patient has already been scheduled for a follow-up appointment, then ideally you would like to have the testing complete and the report back prior to the next visit. It is much more efficient to review test results and draw up a detailed treatment plan ahead of time. Follow up by phone or mail on tests that were not completed. Make sure that all efforts at follow-up are also documented in the patient chart.

There’s another reason for following up, too: What kind of lost revenue will your practice suffer if the patient is not encouraged to keep his follow-up appointment and comply with required testing or referral?

Reviewing your collection and care policies periodically is always a best practice, and essential to ensuring that your staff is prepared to deal with the patient who presents with an HSA plan.

Owen Dahl, FACHE, CHBC, is a nationally recognized medical practice management consultant with over 24 years of experience in consulting for and managing medical practices and author of Think Business! Medical Practice Quality, Efficiency, Profits. He can be reached at odahl@comcast.net or 281 367 3364.

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