Preventing the Co-pay Surprise

Make sure patients understand their obligations to avoid hard feelings at collection time.

By Beverly Loney

Our patient population today is a mix of boomers and "seniors" with varying degrees of understanding of their medical insurance plan benefits. Our financial department is often amazed at how little some patients know about their coverage. What may seem to be a mere idiosyncrasy, however, can result in significant unpleasantness for our patients. With no representative of the insurance company present on whom to vent their frustration, patients sometimes direct their ire at the practice instead.

Technically, of course, it is the patients' responsibility to know their policies, but we find a much more practical approach is to assist our patients so that they have a better under standing of their coverage and financial responsibilities. Following is a summary of the policies we have implemented to ensure both that our practice is paid in a timely manner and that our patients understand their obligations.

The Root of the Problem

We have seen an increase in patients' lack of understanding of their copayment obligations with the growth of highdeductible plans; many patients have qualifying Health Savings Account options. Employees may select the high-deductible plan offered by their employers because of the lower premium cost compared to a PPO. However, when they visit their doctor, it becomes apparent that they did not fully comprehend that their out-of-pocket expenses could be as much as $5,000 during their enrollment year. They are often unprepared and upset when asked to pay for their entire visit or procedure in full.

Additionally, over the past several years managed care plans have been requiring higher co-pays from the patients. Instead of merely an office visit co-pay and possibly a deductible for outpatient or inpatient procedures, plans have become less generous, requiring higher contributions from the patient and therefore placing the onus on the practice to collect. We make efforts to inform our patients when there will be additional co-pays for particular procedures so that they are not surprised when presented with a bill.

From a financial perspective, it is critical for us to collect the fees we are entitled to at the time of visit, rather than incurring the expenses of sending statements and "post-visit" collections. From our patients' perspective, the extra assistance in understanding their financial responsibilities helps them to be prepared without unpleasant surprises.

Advance Notice is Key

With eye examination fees ranging from approximately $50 to more than $200, patients are more apt to pay if given advance notice. When scheduling a patient who carries an insurance plan that we are contracted with, our staff consults a graph that shows our fees, allowed amounts and co-pays for these plans, so we can tell the patient what to be prepared to pay at the time of service scheduling. Also, when the patient is able to provide current insurance information at the time of scheduling, we can go to the company's Web site and learn what amount remains on their deductible. We inform patients of the possibility of a separate fee for the refraction as well.

When patients do not have their plan information available, we provide them with Web site addresses and/or contact phone numbers so that they can obtain details about their plan benefits and financial obligations. Some Web sites provide real-time, detailed history and financial information for their beneficiaries.

Don't Low-ball Them

When insurance details are unavailable, or when patients have no insurance benefits, we quote a fee for the examination stating, "Depending on the extent of the examination, you need to be prepared to pay approximately $200." We ask our staff to quote on the higher end of our fee schedule range. We would rather have our patients be pleasantly surprised when they are asked to pay a lower amount than they were anticipating, as is sometimes the case. Should they have no insurance, we inform them that while we require payment in full at the time of service, they will receive a 15% discount for cash payment.

Mind the Calendar

Our telephone staff are trained to adjust the patient's appointment so that it will coincide with their next payday, or when they are able to pay in full. To keep things safe, we have educated staff to triage the calls to ensure that it is medically appropriate to move the appointment to a later date.

Our telephonic appointment reminder system assists in informing patients when they receive their reminder calls three days prior to their appointments. On each call, the patients are reminded to bring their co-pay, deductible and non-covered payments.

Take the Time to Verify

For insured patients, our goal is to verify coverage before the appointment. We run a report each day showing the type of coverage for those patients with appointments five days out. Some HMOs have online access, so authorization, referral and coverage information is easily obtained. Some managed care plans require the PCP to be contacted to request authorization, so we do that and also contact the patients to inform them of the authorization. At this time the patients are informed that should the authorization not be received in time for their appointment, we will need to reschedule them.

All notes regarding verification/authorization are documented in the electronic medical record and can be viewed by check-in staff to determine how many visits have been authorized. If we learn that coverage is no longer valid, the patients are contacted and informed that they will be required to pay at the time of service. These extra efforts in communication with our patients help make our check-in and collection at check-out a much smoother process.

The Plan for Surgery Patients

For surgical procedures, we hold the patient responsible for payment in full prior to surgery. We go to great lengths to ensure that our patients are informed and prepared. Our senior population especially appreciates this. They want to know where we are located, what route they should take to arrive at our practice, and how much time they need to plan to be there. Generally, they don't like surprises — particularly of the financial kind! Informing them of their co-pays and any out-of-pocket expenses allows them to make arrangements or adjust their budgets accordingly. When possible, this is done a minimum of one week prior to the date of surgery on the preoperative testing day. So many are on a fixed income yet are adamant about paying their bills. The pre-surgery financial counseling provides valuable information to them.

Our Patient Financial Counselor (PFC) meets with each patient to go over these expenses. She contacts each insurance company on behalf of each patient to determine cost. Many times, when a deductible is involved, she finds herself teaching the patient how a medical deductible works.

With the more recent addition of accommodating lenses and optional refractive procedures, patients can "run up the tab," not realizing that they are still responsible for co-pays and deductibles in addition to any optional items they've selected. We understand that they have received a lot of information during their visit and need some time to absorb what was offered and what their options are regarding refractive procedures, intraocular lens options, add-ons, etc.

Toward that end, our practice focus for the last few years has been on educating patients prior to their arrival at the practice. At the time of scheduling, our phone staff use the patient's e-mail to direct them to our Web site to gain educational material about their upcoming appointment. We encourage them to read selected topics correlating with their reason for coming in and to bring questions for our physicians and staff. Once they see the physician, they are less overwhelmed and we feel they are more able to absorb financial discussion.

The PFC contacts the insurance company and determines the amount that will cover for the procedure or device. The deductible is figured in as well as any co-pay and any optional, non-covered amounts.

After our patients have been counseled, they are given forms to sign indicating that they will bring their co-pay amount and will pay prior to their surgery date. We inform them that we may need to reschedule if they are not prepared to pay by the day of the procedure.

When Money is Tight

As we know that there are some patients who just cannot pay, we have developed a procedure where patients who are financially needy or who are requesting a discount are identified early in the surgery scheduling process. When any payment discussion occurs in the lane, the chairside technician documents this on the surgery checklist. The technician gives the patient a form that asks for a copy of their W-2 and other documentation to support financial need. This alerts the PFC that payment arrangements may need to be made. The first step is to determine whether the patient is indigent. If so, the patient is referred to one of several entities such as state AHCCCS (Medicaid) or an alternative healthcare delivery system for low-income patients.

Once this process is completed, arrangements are made for payment. The PFC logs documentation into the computer so that when the patient checks in for surgery, the amount is known and collected prior to the patient being taken to the ASC.

Sometimes it may be that the patient merely cannot pay the full amount prior to surgery. When the patient expresses concern, in some cases we accept partial payments that work with the patient's budget. Sometimes we reschedule the surgery to give the patient time to gather the resources for payment.

Offering financing is another way to assist patients. Although this involves an expense to the practice, payment is usually immediate, eliminating what could be thousands of dollars of expense in billings a nd collections. Recently, the use of credit cards has increased. And while this is an expense to the practice as well, it is far less than would be incurred in sending monthly statements to collect the fee. For this reason, our practice accept them for payment.

Reaping the Benefits

Do we have some patients who are not prepared to pay, or who quickly exit without paying their bills? Of course, but the majority understand that we require payment at the time of service. They've become used to it and often tell our checkout staff what their co-pay amount is prior to her request. For ASC fees, we nearly always receive payment prior to surgery.

Now and then a patient may forget and leave their wallet at home. Their reaction? Generally they are upset and go to great lengths to have their driver pick it up, or they make good on their promise to bring it to their postop appointment the next morning. We know that our educational efforts have paid off — patients are prepared and expecting to pay, so they don't resent our policy.

Spending the extra time and making the extra efforts to inform patients of their financial obligations makes good practice sense. Your A/R is healthier, your billing expense is lower and your patients are happier. OM

Beverly Loney is practice administrator at Fishkind, Bakewell and Maltzman Eyecare and Surgery Center in Tucson. Contact her via e-mail at bloney@eyestucson.com or call 520-293-6740.