Physician Beware: `The Dog Ate My Checkbook`

Physician Beware: ‘The Dog Ate My Checkbook’
Published on OncoTherapy Network (http://www.oncotherapynetwork.com)
Physician Beware: ‘The Dog Ate My Checkbook’
February 01, 2009
By Shirley Grace [1]
You’ve heard it all from patients who have outstanding accounts. How can you tell a genuine plea
for help from a sob story, and when does it matter?
BILLING CLERK: “Hello. May I speak with Mary Smith please?”
MARY SMITH: “Who’s calling?”
BILLING CLERK: “Jan from Dr. So-and-so’s office.”
MARY SMITH: “I’m sorry, there’s no one by that name at this number. [Long silence......*Click*]”
Ah, the joys of patient collections. The only redeeming part of the exchange was that Jan didn’t have
to listen to yet another lame excuse as to why the patient hadn’t paid her outstanding balance.
The creative range of nonpayment excuses from patients seems infinite and sadly shameless. “We
have had ‘Katrina victims’ who can’t even find New Orleans on a map and seen patients out
shopping at expensive jewelry stores the same day they ‘can’t’ pay their copays,” reports an
anonymous office manager on the pediatric-centric e-mail list PedTalk.
“I’ll pay you tomorrow with a credit card” is also popular, says Melissa Torres, clinical administrative
assistant at Bay Crossing Family Medicine in Annapolis, Md. Or, it’s a more subtle rebellion: “They
post-date checks without asking. When you point it out, they say, ‘Well, I have a deposit coming.’”
Or they blame-shift, like this excuse, also culled from PedTalk: “My husband wrote the check for me
to bring but I had it on the visor and it blew out the window (it was early spring and cold) and I’m not
allowed to write checks.” This iron-clad explanation would leave many a front-desk clerk blinking and
mute (and the hinted-at back story provokes much sympathy for her husband).
“I thought insurance would cover it,” is another extremely common defense from
responsibility-duckers, says physician billing consultant Lynn Thomas, who’s with Annapolis,
Md.-based SHR Associates. True, insurance policies can be as easy to decipher as the U.S. tax code,
but such claims are not always so sweetly ingenuous. For some, a glowing coal of resentment burns,
as in: “The doctor doesn’t deserve to make that much; he spent 15 minutes with me and made
$500,” recounts Thomas.
Torres concurs. As a small, patient-centered practice who eschews submitting reimbursement claims
to insurance companies, Bay Crossing attracts many cash clients. After explaining the practice’s
self-pay policies to potentially new patients, she hears “Are you kidding me?” often enough. “It
amazes me what people value, in terms of the doctor’s time and services,” she says.
Yes, you want honesty from your patients. Economic catastrophe happens — seemingly more and
more often in today’s economic climate. How can you resolve an outstanding debt with your patient
if you don’t know what’s really going on?
Kwitcherbellyachin‘
You’ll never eliminate the unpleasant task of chasing down outstanding patient debts, but you can
exact some control. Here are some effective tactics to minimize the kvetching and maximize the
collecting:
Make sure your payment policies are crystal clear. Create a new-patient brochure
outlining all your office policies. Require copays before exams. Train your staff to ask for
payment politely but resolutely, all following the same protocols. Post your payment policies
in the waiting and exam rooms. Develop internal protocols, too, to make sure your staff is
following them. Payment policies can be tricky.
Verify insurance eligibility before an exam. Knowing a patient’s eligibility for a given
procedure — and informing her of the status — will help both of you to stay on top of the bill.
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Physician Beware: ‘The Dog Ate My Checkbook’
Published on OncoTherapy Network (http://www.oncotherapynetwork.com)
Make it a priority to have answers to such key questions before your patients show up for an
office visit. You don’t have to chase what you’ve already collected.
Take your patient at his word — at first. You never know what could be going on in
peoples’ lives. “You have to fight that human tendency to judge, to say, ‘You can’t pay your
bill today but you just drove up in a convertible?’” says Torres. That car might be borrowed or
about to be repossessed. Instead, think flies, honey, and vinegar. Sure, you want — and
deserve — your money, but kindness and flexibility are more likely to get it than skepticism
and disdain. Can he pay half now and then $50 a month? The sincere ones will be grateful,
and it beats not getting paid at all. But make sure everyone understands exactly when and
how to offer payment plan options, if you’re going to offer them.
Ask for some proof of financial hardship. Plenty of economically strapped people just
suck it up and try to make good, never mentioning to you they’re scraping the bottom. So
take care not to “reward” only the squeakiest wheels. For those with frequently empty
wallets, or those requesting a large financial concession on your part, push back. Hand such
patients a “financial hardship” form (that you created), in which the patient outlines what
special dispensation he needs and why. Many patients won’t even bother to fill out the form,
so you needn’t feel obliged to assist them.
Set limits. Unfortunately, a few of those petitioning for financial clemency will prove
themselves less than honorable. Such dissemblers will agree to your offer but not follow up.
But unless you have a “mega-practice” with tens of thousands of patients, you — or more
likely, your front-desk staff — may be able to spot such chronic pretenders, as many identify
themselves with a conspicuous lifestyle that belies their supposed destitution. If every time
you see a patient, says Torres, she’s got a Starbucks coffee and a new purse, yet regularly
claims she’s short on her copay, that’s a clue you’re being played.
Take action as soon as it’s warranted. After no more than three clearly worded,
easy-to-decipher reminder notices, take action. This means what you’ve decided it means
(and what you’ve clearly delineated in your payment policy brochure). Thomas recommends
using a collection agency. You could even dismiss the patient from your practice, if the
problem feels big enough. This route can be hard for physicians to take. A softer approach:
Embargo a hard-core delinquent patient until the debt is satisfied.
Most importantly, don’t be part of the problem. “[Patients] know that physicians in the past
are willing to keep billing and billing,” says Torres. If this is still you, put a stop to it.
Separate clinical and administrative duties. As a physician, you may find it hard to get
tough with a patient on a money issue. There’s an emotional barrier that can be
uncomfortable or embarrassing to cross, as doing so may feel in direct conflict to your inner
beliefs on what it means to be a physician. That’s why so many physicians cave, choosing to
eat the cost of a nonpaying patient. For that reason, says Thomas, “I always recommend that
doctors don’t discuss the finances [with patients].” Assign this task to an appropriate admin
person, one who’s forthright but not a bully. And, importantly, support this bill-collector’s
efforts; don’t undermine him by telling the patient later he doesn’t have to pay “this time.”
Of course, says Thomas, as the physician, you certainly have the right to give the truly needy an
occasional pass if you so choose. Be careful not to cross any legal lines here, such as waiving a
copay here and there, which would violate the terms of your insurance agreement. Make sure, in
fact, that you have a clear policy for financial-hardship discounts, and that you follow it, lest you be
accused of playing favorites, or of having changed your “usual and customary fee,” which would
prompt payers to demand discounts for them. (For a more comprehensive treatment on the potential
pitfall of negotiating patient payments, read “Patients, Pay Up!”)
What does it matter?
Patient accounts in chronic arrears erode your bottom line. Many practices choose to write off the
debt — true, an end to the stress, but it obviously costs you. But so do collection attempts
throughout the year. Mailing statements — about 60 cents apiece. A reminder phone call — about $5
in staff time. Research on a delinquent account — about $30. Bad debt due to uncollected
deductibles runs practices about 18 percent annually, with the self-pay default rate at 30 percent or
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Physician Beware: ‘The Dog Ate My Checkbook’
Published on OncoTherapy Network (http://www.oncotherapynetwork.com)
more. Even if you use a crack collection agency, you’ll only see a portion of the resolved debt, after
the agency takes its cut.
So get smart about patient pleas by pre-empting much of it with good preparation and clear
communication. And don’t give up.
Shirley Grace is an associate editor on staff with Physicians Practice. She can be reached at
shirley.grace@cmpmedica.com.
This article originally appeared in the February 2009 issue of Physicians Practice.
Disclosures:
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[1] http://www.oncotherapynetwork.com/authors/shirley-grace
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