Physicians Practice PEARLS: HSAy What?

November 1, 2008
Owen Dahl

High-deductible health plans like health savings accounts are becoming more common, and that means you’ll have to work harder to collect from patients.


A health savings account, or 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. Like it or not, they’re becoming more prevalent. Successfully collecting HSA-patient copays prior to the office visit and ensuring that these patients comply with recommended follow-ups can be a challenge.

Case in point: A patient visits your practice. He pays $73 prior to seeing you for a routine visit. Later, he receives a bill from your office for an additional $35. He’s understandably annoyed. Why is he 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!

Another example: This patient was also scheduled for an MRI as a follow-up to his office visit. Because of his high deductible, the patient says 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?

To 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.

  • Use calm, polite reasoning. Politely explain to your patient about the increased level of service.

  • Communicate your HSA payment policies. Inform your HSA patients in writing 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.

As for the second issue of the delayed lab tests, since you already have an established physician-patient relationship with this person, 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 more than 24 years of experience in healthcare consulting. He can be reached at odahl@comcast.net.

This article originally appeared in the November 2008 issue of Physicians Practice.