Improving Patient Payment at the Time of Service

Executive Summary

As the number of high-deductible plans has increased, many patients are unable to pay higher medical bills associated with them. This means that healthcare organizations and practices need to prioritize improving their success rate in collecting on these bills. However, providers also need to be aware of the risks accompanying billing and collecting. 

Recommended Actions

• Ensure that your practice is familiar with the changes to billing requirements established by the No Surprises Act.
• Ensure that staff members remain courteous and respectful when dealing with patients, regardless of the number of times they contact the same patient about an unpaid bill.
• Consider developing a script for staff members that covers what to say when discussing unpaid bills with patients. A script could make staff members more comfortable dealing with overdue accounts.

Collecting from patients is one of the more difficult aspects of medical practice management. But few medical practices will survive without collecting a high percentage of amounts due from patients, whether they are insured or not.

Medical practices must make a concerted effort to collect copayments, coinsurance, deductibles, amounts for services not covered by insurance and charges to uninsured patients. The reimbursement rates that third-party payers allow take into account what medical practices collect from patients. Today’s high deductible health plans mean patients are less likely to satisfy their deductibles until well into the plan year.

The best ways to ensure that your medical practice collects patient payments is to:

• Verify insurance
• Estimate the patient’s responsibility
• Collect as much of that as possible before, or just after, medical services are provided
• Provide a number of payment options to make it easy for patients to pay
• Establish an effective program to collect amounts that patients cannot pay at the time of service
• Monitor the success of collection efforts[1]

Studies from Medical Economics indicate that collection rates for insured patients can be as low as 50% to 70% after the patient walks out the door. The rate continues to decline as time passes and before an account is turned over to a collection agency. Similarly, the collection rate can be as low as 10% for uninsured patients. And surprisingly, studies also indicate that more than half of patients are willing to pay $200 to $500 or more by credit or debit card at the time of a physician visit.[2]

The copayment for an office visit is usually easy to determine. It’s either printed on the patient’s insurance card or available when verifying the patient’s insurance. Most patients know it is due at the time of service and medical practices should make an effort to collect copayments from every patient.

When a patient can’t pay or says they don’t have their checkbook or credit card, have staff complete a form or log indicating the patient’s name, amount of copayment and why it could not be collected. Make sure patients know that they will be contacted in the event payment is not received within two weeks. Better yet, give them instructions and tell them they can make a payment through your website’s patient portal. The manager and/or physicians should regularly monitor copayment collection efforts and make tweaks as needed. With patients who can’t pay, you may want to set up a payment plan during the encounter.

Deductibles and coinsurance can be more difficult to estimate, particularly if a range of services is provided. Some services — such as preventive services — might not be subject to coinsurance or deductibles. Other services could be subject to confusing reimbursement rules, such as those for multiple procedures. Some services might not even be covered. Regardless, it is usually better to make the best estimate you can and attempt to collect that amount at the time of service. Some groups collect 25% to 50% of their best estimate and counsel the patient that they will be billed the remainder when a claim is adjudicated.[3]

It is a good investment to train staff in these matters. Studies suggest that you need to know what patients owe and “improve the ask.”[4] Some employees are instinctively better at collecting from patients, while others do not handle it confidently. Those who are better at collections can train other staff. Rather than asking a patient if they can pay their bill today, ask, “How would you like to pay your bill today?” That small difference often improves collection rates and makes it easier on staff.

If your practice does not have a written payment policy, write one and post it in the office and on your website. Keep copies available to hand out to patients.

Finally, keep the No Surprises Act (NSA) in mind when billing patients. NSA protects patients covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. NSA went into effect in January 2022, so it is important that healthcare providers know what the new law requires of them and their billing practices. NSA went into effect by way of two interim final rules, Requirements Related to Surprise Billing Part I and Part II.

Here are articles and other resources that will help your medical practice improve collection efforts: 

Managing Patient Payment Toolkit
Why Your Practice Needs A Solid Patient Payment Policy
Sample Payment Policy for Medical Practices
Collection Tips: Copays, Deductibles and No-shows 
Optimizing Patient Collections
Eight Simple Metrics for Monitoring Your Medical Practice
Interest & Finance Charges
13 Steps to Increase Patient Payment Collections

Lessons Learned 

• To set expectations early, discuss payment with patients before a visit and give them estimates of how much they’ll be expected to pay out of pocket.
• Vet patients prior to a visit to better understand whether your practice can expect payment. This can include running a credit report on a patient. 
• Document and keep accurate notes when patients do not pay in full after a visit to help aid the collection process.

Potential Damages

If healthcare organizations or providers violate the No Surprises Act, they may be subject to costly civil fines or other corrective measures. However, the frequency of such violations is relatively low. 

[1] Lucien Roberts. 10 Collection Tactics for High-Deductible Patients. Physicians Practice. December 7, 2016.
[2] Hanny Freiwat. Leveraging the Front Office, Strategies to Increase Your Practice’s Cash Flow. Medical Economics. April 30, 2015.
[3] Another issue is that some managed care physician service contracts, also called “participation agreements,” can be read to preclude medical practices from collecting coinsurance and deductibles before the claim is adjudicated. Although this language is not as prevalent, it still exists. Some physicians have been successful negotiating modifications to those sections or have received clarifications that would allow a physician to collect a reasonable estimate on the date of service with a refund if a credit balance results. In any event, those clauses could be an obstacle, but it’s worth asking the plan if one can collect a reasonable estimate of deductibles and coinsurance. In fact, most contracts require medical practices to make a reasonable effort to collect coinsurance and deductibles.
[4] Lucien Roberts. 10 Collection Tactics for High-Deductible Patients. Physicians Practice. December 7, 2016.