Tips for Collection Problems with Per Episode HMO Patients

Scenario: A patient comes to you for an evaluation, then is a no-show for 2 follow-up treatment dates. The account automatically gets charged no-show fees. But your attempts to get the patient back on schedule fails. Meanwhile, the HMO pays you a fraction of your contracted rate as a provider in the network. And your attempts to get the patient to make payments are met with empty promises or even hangups. What are you to do?

First, check what your contracted rate is. In some instances, your contract may pay one fee no matter the number of visits. You may find that the HMO is piece-mealing you until your treatments equal or surpass this rate. In the case of fewer DOS than meets this rate, you're getting shortchanged... not to mention it's generating a lot of extra work for your billing person.

For example, in the case of our example patient, the evaluation was billed at $125. The HMO paid $62.50. The patient owed $100 for 2 no-shows. I had no luck with the patient -- the patient could care less about the treatment program. I checked the EOB which indicated that the patient's policy included a 50% co-pay. I called the HMO and noted that our contract was to get paid $456 per episode, no matter how many or how few appointments there were. GUESS WHAT? THEY ENDED UP PAYING THE BALANCE OF THE $456. All it took was pointing this out to the HMO provider relations rep. TRY IT MAYBE IT WILL WORK FOR YOU!

Copyright © 2001 Leer Technical Communications

Monitoring Outstanding Accounts

How often you monitor your Accounts Receivable directly affects the health of your organization and the bottom line. It's great to generate revenue but it's better to collect it. Because a high A/R does nothing for your cashflow. And to keep a business running you need cash. Otherwise how will you pay bills and payroll?

Sending out period statements is important. But rarely do statements solve the problem of getting cash in the door. If you bill insurance carriers, you already know how difficult it is getting paid in a timely fashion. But what about getting paid by the patient for the patient's portion of billable charges as well as any non-reimbursed balance?

Establish Financial Responsibility Up Front

If you aren't already doing it, include a financial agreement with the new patient forms. State right on the agreement that this agreement is a "letter of protection" in legal cases and that the patient by signing understands that he/she is responsible for any balance not covered by insurance. This protects you in the case that payment of your fees are delayed because of a legal process (such as auto accident or Worker's Compensation denial) or the patient seems to believe that the bill will go away because the insurance company did not pay.

Get on the Phone and Call Patients Who Are Not Paying

This is your livelihood. If you are like most of us, you don't work for free. So, why wait for your outstanding accounts to pay when they aren't getting the message from your weekly or monthly customer statements?

Talking money is actually easier on the phone than in person. However, I highly suggest that the person doing the calling be somebody other than the therapist who saw the patient. This makes your call more official and onerous that the practice has been fair and understanding, but it's high time that the patient took responsibility and paid up. Follow the K.I.S.S. method - "keep it simple sport". If necessary, write out a simple script, such as:

"Hi. This is [your name] from [practice name]. I am calling because you have an outstanding balance with us for the physical therapy you received. Will you come in today to resolve this?"

Saying "today" keeps you on track for receiving payment and resolving this whole issue immediately. Be prepared for the inevitable objections you will receive:

  1. "But I don't owe anything more because insurance took care of it." Note that the balance corresponds to the portion for which the patient is responsible and which was not covered by insurance (e.g., copays and EOB denials). Indicate that you expect payment immediately (say, within the next 2 days) to stress the urgency. You can also say, "Unfortunately we are not a bank. I hope you can appreciate that we can't afford to finance everybody's balance."
  2. "I can't pay, I don't have any money." Suggest putting the payment on the patient's credit card, which is a win-win for both of you. Otherwise discuss your willingness to set up a payment plan to pay off the full amount within a short period of time.
  3. "I don't owe anything, I won't pay!" If the patient is unwilling to pay and particularly if he/she is abusive on the phone, simply say that you will have to take the patient to court.

Follow the Fair Debt Collection Practices Act

Whatever you do to collect outstanding account balances, be courteous, instructional, and to-the-point. And by all means make sure you comply with the Fair Debt Collection Practices Act (http://www.ftc.gov/os/statutes/fdcpa/fdcpact.htm).

The purpose of this Federal act is to "eliminate abusive debt collection practices by debt collectors, to insure that those debt collectors who refrain from using abusive debt collection practices are not competitively disadvantaged, and to promote consistent state action to protect consumers against debt collection abuses." This act covers the "don'ts". It's OK for a patient to swear at you and slam the phone but it won't help your case if you do it. Besides, your victory can always be won in court as long as you have a financial agreement with the patient (as mentioned earlier).

Problem Checklist

  1. Have each new patient sign a financial agreement up front before treatment.
  2. Send out periodic statements.
  3. Collect payment from patient at each appointment (at least once a week to cover the patient balance).
  4. Monitor your A/R regularly.
  5. Stay on top of claims delayed by insurance and EOB denials.
  6. Call patients as soon as you know insurance payments have been exhausted and resolve immediately.


Copyright © 1999 Leer Technical Communications