Medical Practice Collections Efforts Just Became Easier

June 14, 2014
P.J. Cloud-Moulds

When patients refuse to pay their cost-share for healthcare, you have a surprise go-to resource to help get you paid.

This was an interesting week, with many, many challenges. A conversation I had with some staff members resulted in an absolute epiphany. I want to share that with you now. This is something that will not cost you or your staff more than about thirty more seconds of time; with the return on investment infinite.

You know those patients, the ones who are considered "professional debtors," the ones that will never pay? They will pay a minimum amount, every three months, to stay out of collections. They call your staff and remind them that they are "long term patients," and ask, "How could you send me to collections?"

You might respond: Mr. Smith, you are refusing to pay for your share of the cost for the care you receive. This means you are outright stealing from the practice you are attending. This also means you could be committing insurance fraud.

Let me explain why your patient could be committing fraud:

• Mr. Smith has a deductible, copay, or coinsurance associated with his health plan. If he hasn't paid this cost share, likely your front-office staff were provided incorrect benefit information or neglected to collect this amount at the time of service. You send him three statements, and still receive no payment. You might even experience a phone call where he yells at your front-office staff or the billing department.

• Your next course of action is to call the specific insurance company and basically "report the patient." Yes, this is your right and business responsibility. Each insurance company has their own process, you just have to ask.

• What will typically happen is this: Call the insurance company and let them know the patient refuses to pay. They will ask you to send in an appeal letter stating this, and ask how many statements have been sent, phone calls made, etc., (basically, your collections efforts). The insurance company will then review the appeal and send a letter to the patient telling him he has to pay you. If the patient still refuses to pay, the insurance company will reconsider the claim and pay you the patient's deductible amounts, and then adjust those amounts on the patients' deductible balance. This will result in the patient still owing deductible amounts to another practitioner.  This means that if the insurance company shows the patient had "met" $3,500.00 of their deductible, but did not pay you $500.00, then the amount will go back up to $4,000.00. The only way a patient can truly "meet" their deductible, is if they pay their bill.

• Although copay and coinsurance were not mentioned in this example, those amounts still apply to out-of-pocket maximums. When out-of-pocket maximums are met, then the insurance company pays 100 percent of expenses (most often). If the patient is not paying their portion, then they are stealing from the insurance company too.

Now, I've never been a fan of insurance companies, as you well know, but why not utilize a resource when you have one? I think this is a golden-nugget type of find and I couldn't wait to share it with you all.