In office collections

[Carbon13]

I have a question for those of you in private practice. This is regarding same day collections for services rendered.

Do you collect deductible payments on the same day of service?

Example:
New patient comes in for treatment of a painful, arthritic joint. You perform new patient exam, X-rays, Injection.

The patient's insurance plan has a $20 Co-Pay and $2,500 unmet of a $5,000 deductible.

After treatment and before the patient leaves the office,
You collect the $20 dollar Co-Pay which covers the E/M code

Now,
Do you collect the money for the X-ray & injection ? Or do you file with insurance & wait for the patient to get the bill (EOB) in the mail and then hope they pay you at a later date ?

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[dtrack22]

Do you collect the money for the X-ray & injection ?

yes, on day of service. We collect what we anticipate the patient owing, then bill through insurance and if they overpaid our office writes them a check.

 

[Scrantonicity]

yes, on day of service. We collect what we anticipate the patient owing, then bill through insurance and if they overpaid our office writes them a check.

Yeah, same here. It's really the only way to run a practice these days. Patients will pay every one of their other bills before they'll pay your doctor bill (with few exceptions). If they say they can't pay, offer to reschedule now that they know the fee---you're not missing out on much if they weren't going to pay the bill later anyways. It's becoming more and more common in physicians' offices of all specialities, so fewer and fewer patients are surprised by this policy.

 

[GreenHousePub]

How about for a diabetic foot wound - not clinically infected - what would you do then if the patient declines to pay?

 

[dtrack22]

You ask them to pay something toward the cost of the visit and offer to put them on a payment plan. If that doesn’t work then you decline to see them.

 

[ExperiencedDPM]

You have to read the terms of the insurance contract. Some will not allow you to collect any money other than the copay until the claim has been submitted and processed.

Insurers aren’t always happy about you taking money from a patient and then you potentially owing the patient money. If that patient never returns, most offices will realistically not chase the patient to provide a refund.

The problem involves an “assumption”. You find out the patient hasn’t met the deductible by checking online or via phone. You may not know that the patient forgot to tell you she saw another doctor last week and that doctor sent in a large bill. Additionally, you are assuming that all the codes you bill will be approved and approved at the amount you anticipate.

Be careful, you may be in violation of your agreement with the insurer. As much as you want your money up front and may have valid concerns that the patient may not pay, the insurance protocol is likely that you send the claim to them, they process the claim and pay you or tell you the exact amount the patient owes.

Please be very careful. A colleague of mine who is an honest and great doctor was removed from the largest insurer in his area and the financial impact on his practice is something that may eventually put him out of business. All he did was collect deductibles up front for several months.

Check your contract or the rules of the insurer or it can be a very costly error.

 

[Scrantonicity]

You have to read the terms of the insurance contract. Some will not allow you to collect any money other than the copay until the claim has been submitted and processed.

Insurers aren’t always happy about you taking money from a patient and then you potentially owing the patient money. If that patient never returns, most offices will realistically not chase the patient to provide a refund.

The problem involves an “assumption”. You find out the patient hasn’t met the deductible by checking online or via phone. You may not know that the patient forgot to tell you she saw another doctor last week and that doctor sent in a large bill. Additionally, you are assuming that all the codes you bill will be approved and approved at the amount you anticipate.

Be careful, you may be in violation of your agreement with the insurer. As much as you want your money up front and may have valid concerns that the patient may not pay, the insurance protocol is likely that you send the claim to them, they process the claim and pay you or tell you the exact amount the patient owes.

Please be very careful. A colleague of mine who is an honest and great doctor was removed from the largest insurer in his area and the financial impact on his practice is something that may eventually put him out of business. All he did was collect deductibles up front for several months.

Check your contract or the rules of the insurer or it can be a very costly error.

What??? How then does the patient meet their deductible? If it's only when they get a bill in the mail--good luck getting that on the back end. I swear we are turning into slaves...

 

[ExperiencedDPM]

What??? How then does the patient meet their deductible? If it's only when they get a bill in the mail--good luck getting that on the back end. I swear we are turning into slaves...

Again, here are the reasons that it may be in violation to collect up front:

1). Fee schedules often change without notice and you may be charging the patient an inaccurate fee. As you know, the fee you charge is not necessarily the amount that will go toward the deductible.

2). The patient may have already seen another provider who did not collect money but sent in a bill yesterday. The deductible may end up being taken from HIS fee. So when the patient gets a bill from that doctor, but has already paid you, someone ain’t gonna’ be happy. And you’ll be giving that patient a refund.

3). You don’t know what determination an insurer will make in the claim. They may not pay for all services you’ve billed.

As far as “turning into slaves”, you have no one to blame but yourself. This IS the insurance system, and no one twisted your arm to participate. Yes, many would not survive without participating, but if you signed the contract, you can’t complain.

My friend is an orthopedic surgeon and does NOT participate with insurance. He works 70% less than his colleagues and makes a load of money. His colleagues do 10-15 cases a week. He does 3, but charges $12,000 for a knee scope. So he makes $36,000 a week on just those 3 patients.

Do the math. If the insurance game has you fed up, drop out, work less and make more money.

When’s the last time you heard a cosmetic or plastic surgeon complaining about insurance?

My college friend lives in NYC and is very wealthy. His wife went to a well marketed “cosmetic” foot surgeon in NYC and had some work done. She had 3 arthroplasties and was charged almost $20,000. The doctor charged for everything including local anesthesia, nerve blocks AND dressings. That’s all for less than 25 minutes of work.

An insurance company would pay maybe $400 for the first toe and maybe a total of 400-500 for the other two toes combined. So you’d get about $800 total IF you’re lucky. And you can’t get paid for the nerve block or dressings.

So you make 800 bucks and the non participating doc in NYC makes $20,000 for the same procedures. And YES, there are wealthy and not so bright patients who will pay and do pay.

 

[Scrantonicity]

Again, here are the reasons that it may be in violation to collect up front:

1). Fee schedules often change without notice and you may be charging the patient an inaccurate fee. As you know, the fee you charge is not necessarily the amount that will go toward the deductible.

2). The patient may have already seen another provider who did not collect money but sent in a bill yesterday. The deductible may end up being taken from HIS fee. So when the patient gets a bill from that doctor, but has already paid you, someone ain’t gonna’ be happy. And you’ll be giving that patient a refund.

3). You don’t know what determination an insurer will make in the claim. They may not pay for all services you’ve billed.

As far as “turning into slaves”, you have no one to blame but yourself. This IS the insurance system, and no one twisted your arm to participate. Yes, many would not survive without participating, but if you signed the contract, you can’t complain.

My friend is an orthopedic surgeon and does NOT participate with insurance. He works 70% less than his colleagues and makes a load of money. His colleagues do 10-15 cases a week. He does 3, but charges $12,000 for a knee scope. So he makes $36,000 a week on just those 3 patients.

Do the math. If the insurance game has you fed up, drop out, work less and make more money.

When’s the last time you heard a cosmetic or plastic surgeon complaining about insurance?

My college friend lives in NYC and is very wealthy. His wife went to a well marketed “cosmetic” foot surgeon in NYC and had some work done. She had 3 arthroplasties and was charged almost $20,000. The doctor charged for everything including local anesthesia, nerve blocks AND dressings. That’s all for less than 25 minutes of work.

An insurance company would pay maybe $400 for the first toe and maybe a total of 400-500 for the other two toes combined. So you’d get about $800 total IF you’re lucky. And you can’t get paid for the nerve block or dressings.

So you make 800 bucks and the non participating doc in NYC makes $20,000 for the same procedures. And YES, there are wealthy and not so bright patients who will pay and do pay.

1. If you only deal with a few insurance companies, you have a pretty good feel for the accurate fee. Sure, it may change without notice, but this does not happen very often. Valid concern, but really not that impactful.

2. Sure this MAY happen--however, deductibles are getting higher and higher, so up until about September/October or later this is RARELY an issue.

3. Again, if you're only dealing with a very few insurance companies, it's pretty easy to predict what is covered--especially if the services you're billing are consistently being covered.

While I agree the concerns are valid---these are incidents that happen so infrequently in my experience. I've had to issue very few refunds for overpayment.

I'm sorry--but for many areas dropping insurance altogether would be career suicide. I know you acknowledged this, but yeah--it's just not viable or sustainable in the current climate. I agree there are some "less bright" patients that would pay exorbitant fees to have procedures done on their feet...but in many regions (especially rural), this would be like winning the jackpot. I think in reality, patients are getting smarter and smarter about their insurance coverage--and finding doctors that will accept their insurance by using the Internet. If you don't accept ANY insurance, why are they going to see you when they can see the foot & ankle orthopod across town for a fraction of the price with their insurance?

A "cosmetic" podiatrist in New York City is so far removed from normal podiatry practice that I think this is a terrible example to bring up, just sayin'. So we should just stop complaining, drop insurance, and all become cosmetic podiatrists? No thanks--maybe being a slave is better if I'm at least able to pay my bills.

 

[dtrack22]

There probably used to be an argument to drop insurance contracts and just be out of network. It seems that fewer plans are still allowing out of network benefits. So before, the patient may have had to pay higher fees because there was no negotiated rate with the provider up until their deductible was met, but once that coverage kicked in, insurance would pay. I'm seeing more and more plans (mine included) where insurance won't pay a penny to anyone that isn't in network. The patient is responsible for all of it. I could see markets where that would be disastrous for anyone who wants to do more than treat toenail fungus and ingrowns and heel pain.

 

[ExperiencedDPM]

1. If you only deal with a few insurance companies, you have a pretty good feel for the accurate fee. Sure, it may change without notice, but this does not happen very often. Valid concern, but really not that impactful.

2. Sure this MAY happen--however, deductibles are getting higher and higher, so up until about September/October or later this is RARELY an issue.

3. Again, if you're only dealing with a very few insurance companies, it's pretty easy to predict what is covered--especially if the services you're billing are consistently being covered.

While I agree the concerns are valid---these are incidents that happen so infrequently in my experience. I've had to issue very few refunds for overpayment.

I'm sorry--but for many areas dropping insurance altogether would be career suicide. I know you acknowledged this, but yeah--it's just not viable or sustainable in the current climate. I agree there are some "less bright" patients that would pay exorbitant fees to have procedures done on their feet...but in many regions (especially rural), this would be like winning the jackpot. I think in reality, patients are getting smarter and smarter about their insurance coverage--and finding doctors that will accept their insurance by using the Internet. If you don't accept ANY insurance, why are they going to see you when they can see the foot & ankle orthopod across town for a fraction of the price with their insurance?

A "cosmetic" podiatrist in New York City is so far removed from normal podiatry practice that I think this is a terrible example to bring up, just sayin'. So we should just stop complaining, drop insurance, and all become cosmetic podiatrists? No thanks--maybe being a slave is better if I'm at least able to pay my bills.

I’m not sure how long you’ve been in practice, but I can tell you that dismissing my comments is naive.

Whether or not you agree with my comments has absolutely no impact on me. The comments I made are factual, no matter how you want to spin it to work for you. I am fully aware of the insurance rules and regulations since I’ve been a paid consultant for these exact types of issues for over 15 years.

And once again, whether or not you agree with my comments or assessment does not negate the fact that you may be in VIOLATION of your agreement with the insurer.

I don’t advocate cosmetic surgery and my NYC example was just that, an example. However, there are many doctors across the country who don’t accept insurance.

My point is that it just doesn’t make sense to voluntarily participate with carriers to allow your practice to survive, and then complain about the reimbursement or rules. Regardless of your rationale that you need to participate to survive, you still signed on voluntarily.

The most important take home point is that regardless of your financial needs and concerns, taking money up front from a patient may be in violation of your agreement and may jeopardize your participation.

 

[Scrantonicity]

I’m not sure how long you’ve been in practice, but I can tell you that dismissing my comments is naive.

Whether or not you agree with my comments has absolutely no impact on me. The comments I made are factual, no matter how you want to spin it to work for you. I am fully aware of the insurance rules and regulations since I’ve been a paid consultant for these exact types of issues for over 15 years.

And once again, whether or not you agree with my comments or assessment does not negate the fact that you may be in VIOLATION of your agreement with the insurer.

I don’t advocate cosmetic surgery and my NYC example was just that, an example. However, there are many doctors across the country who don’t accept insurance.

My point is that it just doesn’t make sense to voluntarily participate with carriers to allow your practice to survive, and then complain about the reimbursement or rules. Regardless of your rationale that you need to participate to survive, you still signed on voluntarily.

The most important take home point is that regardless of your financial needs and concerns, taking money up front from a patient may be in violation of your agreement and may jeopardize your participation.

Why does it matter how long I've been in practice? The situation with insurance changes all the time--so really the only thing that matters is what is happening NOW. I don't care how it was in the 80's or 90's.

I'm pretty sure I didn't "dismiss" your comments. I said they were valid concerns--but they didn't do much to sway me from accepting payment up front. I do need to go back and read the contracts and see if it is in fact a VIOLATION. If so, there's nothing I can say to that.

While I'm sure the the insurance companies appreciate you sticking up for them--I'm pretty sure it's not a violation to complain about reimbursements and/or rules. If we don't complain and take action, how will things ever change? Prime example: Medicare was about to screw us over with our E/M codes. We complained. We wrote our congressmen. We paid our APMA dues and they fought for us. Crisis narrowly averted.

Now, I'm not minimizing your expertise on the subject. I'm just saying it's B.S. that we can't accept ANY form of payment (aside from the co-pay) up front. If it is in fact the truth, it's still B.S. and I'll still complain about it.

 

[ExperiencedDPM]

Why does it matter how long I've been in practice? The situation with insurance changes all the time--so really the only thing that matters is what is happening NOW. I don't care how it was in the 80's or 90's.

I'm pretty sure I didn't "dismiss" your comments. I said they were valid concerns--but they didn't do much to sway me from accepting payment up front. I do need to go back and read the contracts and see if it is in fact a VIOLATION. If so, there's nothing I can say to that.

While I'm sure the the insurance companies appreciate you sticking up for them--I'm pretty sure it's not a violation to complain about reimbursements and/or rules. If we don't complain and take action, how will things ever change? Prime example: Medicare was about to screw us over with our E/M codes. We complained. We wrote our congressmen. We paid our APMA dues and they fought for us. Crisis narrowly averted.

Now, I'm not minimizing your expertise on the subject. I'm just saying it's B.S. that we can't accept ANY form of payment (aside from the co-pay) up front. If it is in fact the truth, it's still B.S. and I'll still complain about it.

Don’t make assumptions that I’m referring to the 80s or 90s. I asked how long you’ve been in practice to determine if you’ve been on your own long enough to understand that what you think is ideologically correct may not be contractually correct.

I’m not “sticking up” for the insurance companies. I’m just stating the facts. Participating with an insurer is 100% voluntary. I understand you may feel that you can’t survive without them, but again, you chose to participate. And unfortunately the insurers have the power to call the shots. It’s harsh reality.

I’m not sure what you meant when you said you don’t need to go back and read the contracts to see if you’re in violation. Violating a contract is something you should be very concerned about and something you shouldn’t take lightly. It has the potential to impact your future participation and possibly even include financial penalties.

As in all aspects of practice, it’s always prudent to follow the rules. It’s a safe way to sleep well at night. If you don’t agree with the rules and can solicit the insurer and discuss your concerns. It won’t always fall on deaf ears. Two years ago I solicited a major national insurer and persevered and as a result I was able to change a national policy on a particular issue. It ultimately benefited every doctor in the country that provides a particular service. Their policy was unrealistic and antiquated and I supplied studies and literature to support my view. It took 9 months and hundreds of calls with their policy makers, medical directors, coding experts, etc., but it worked and the policy was changed nationally.

If you have concerns, do whatever is in your power to make changes. Sometimes it works and sometimes it doesn’t. But it’s worth the effort.

 

[Scrantonicity]

Don’t make assumptions that I’m referring to the 80s or 90s. I asked how long you’ve been in practice to determine if you’ve been on your own long enough to understand that what you think is ideologically correct may not be contractually correct.

I’m not “sticking up” for the insurance companies. I’m just stating the facts. Participating with an insurer is 100% voluntary. I understand you may feel that you can’t survive without them, but again, you chose to participate. And unfortunately the insurers have the power to call the shots. It’s harsh reality.

I’m not sure what you meant when you said you don’t need to go back and read the contracts to see if you’re in violation. Violating a contract is something you should be very concerned about and something you shouldn’t take lightly. It has the potential to impact your future participation and possibly even include financial penalties.

As in all aspects of practice, it’s always prudent to follow the rules. It’s a safe way to sleep well at night. If you don’t agree with the rules and can solicit the insurer and discuss your concerns. It won’t always fall on deaf ears. Two years ago I solicited a major national insurer and persevered and as a result I was able to change a national policy on a particular issue. It ultimately benefited every doctor in the country that provides a particular service. Their policy was unrealistic and antiquated and I supplied studies and literature to support my view. It took 9 months and hundreds of calls with their policy makers, medical directors, coding experts, etc., but it worked and the policy was changed nationally.

If you have concerns, do whatever is in your power to make changes. Sometimes it works and sometimes it doesn’t. But it’s worth the effort.

I said I DO need to go back and read the contract.

But yeah, sounds like we're in agreement. If we don't like the rules, we should and do complain about it--earlier you said we can't complain--yet you did just that and changed a national policy. Thanks for that! The fact that it is "voluntary" to participate in insurance doesn't mean we can't at least try to change things.

 

[ExperiencedDPM]

I said I DO need to go back and read the contract.

But yeah, sounds like we're in agreement. If we don't like the rules, we should and do complain about it--earlier you said we can't complain--yet you did just that and changed a national policy. Thanks for that! The fact that it is "voluntary" to participate in insurance doesn't mean we can't at least try to change things.

Complaining without action is of no value. If you have an issue and offer a soution it’s a different story. In my career, I’ve distanced myself from those who complain but take no action. They have a much different mindset than me.

 

[Scrantonicity]

Complaining without action is of no value. If you have an issue and offer a soution it’s a different story. In my career, I’ve distanced myself from those who complain but take no action. They have a much different mindset than me.

With respect, not sure what you're doing here then. This is a great place for us to semi-anonymously blow off some steam. Of course, some are way more negative than others. I just roll my eyes and laugh at them. No need to get all haughty about it.

 

[ExperiencedDPM]

With respect, not sure what you're doing here then. This is a great place for us to semi-anonymously blow off some steam. Of course, some are way more negative than others. I just roll my eyes and laugh at them. No need to get all haughty about it.

Ha, all haughty? So what does that mean? I express my opinion that I’ve found it much more productive in life to be around “doers” vs “complainers” and that’s all “haughty”?

And what do you mean that you don’t know what I’m doing here? Does that mean that I shouldn’t be on this site because people complain? Sorry, don’t get your point.

Blow off steam all you want. I’m trying to provide a little guidance for those who are open minded enough to listen. Whether or not you find value in my guidance will have no bearing on me, my income, etc.

Complaining to “blow off steam” is great but accomplishes nothing. I guess I just have a different philosophy in life. If I hit an obstacle I bitch about it like everyone else. Then I figure out a way to beat it (legally) by fighting for what I think is correct.

I already wrote about my banging away and perseverance to change a national policy with an insurer. And I’ve done this in other venues. As I’ve also stated on this site,
I had applied for privileges at a hospital with an old school orthopedic surgeon who thought I should cut nails only. The surgical privilege form had literally 3 procedures on it. I created my own form that was almost 5 pages including ORIF of fractures and rearfoot/ankle. He laughed at me and embarrassed me (or at least tried) at a meeting and only granted me 3 privileges which were all simple digital procedures. He fired me up and I challenged him (much to the chagrin of the existing pods on staff who told me not to rock the boat). I went after him relentlessly and went to administration, legal, and everyone in between. I challenged HIS foot and ankle privileges since he hadn’t done a foot or ankle case in 6 months. Well, after pissing off everyone and 4 months later,I was granted every privilege requested with the exception of skin grafting/obtaining a graft. I let that slide since even the orthpods had plastics assist on those.

So I’ve spent my career complaining about a lot of crap also, but then decided to try to make changes. Sometimes I succeeded and more times I failed. But I always tried.

And you have the ability to do the same.

 

[Scrantonicity]

Ha, all haughty? So what does that mean? I express my opinion that I’ve found it much more productive in life to be around “doers” vs “complainers” and that’s all “haughty”?

And what do you mean that you don’t know what I’m doing here? Does that mean that I shouldn’t be on this site because people complain? Sorry, don’t get your point.

Blow off steam all you want. I’m trying to provide a little guidance for those who are open minded enough to listen. Whether or not you find value in my guidance will have no bearing on me, my income, etc.

Complaining to “blow off steam” is great but accomplishes nothing. I guess I just have a different philosophy in life. If I hit an obstacle I bitch about it like everyone else. Then I figure out a way to beat it (legally) by fighting for what I think is correct.

I already wrote about my banging away and perseverance to change a national policy with an insurer. And I’ve done this in other venues. As I’ve also stated on this site,
I had applied for privileges at a hospital with an old school orthopedic surgeon who thought I should cut nails only. The surgical privilege form had literally 3 procedures on it. I created my own form that was almost 5 pages including ORIF of fractures and rearfoot/ankle. He laughed at me and embarrassed me (or at least tried) at a meeting and only granted me 3 privileges which were all simple digital procedures. He fired me up and I challenged him (much to the chagrin of the existing pods on staff who told me not to rock the boat). I went after him relentlessly and went to administration, legal, and everyone in between. I challenged HIS foot and ankle privileges since he hadn’t done a foot or ankle case in 6 months. Well, after pissing off everyone and 4 months later,I was granted every privilege requested with the exception of skin grafting/obtaining a graft. I let that slide since even the orthpods had plastics assist on those.

So I’ve spent my career complaining about a lot of crap also, but then decided to try to make changes. Sometimes I succeeded and more times I failed. But I always tried.

And you have the ability to do the same.

Don't get me wrong--I think you're a great contributor to this site. I think you live up to your name with loads of experience. It does feel like you're talking down to me though. Just in this thread you've accused me of being naive as well as implied that I'm just a complainer that you and others with your mindset should "distance" yourselves from. And all this because I was making a case as to why I think insurance companies should stay out of how we collect the "other" money from our patients so we're not working for free (i.e. slavery). You made your case for the insurance companies, and I just gave my perspective as to why I think it doesn't hold water. Wrong or not, whether it accomplishes anything or not, it was my opinion.

I'm well aware that I have the ability to take action. I've gotten into similar conflicts with hospitals. I was the first podiatrist in two of the hospitals that I'm affiliated with. In each case, I had to spend a lot of time talking to the CEOs of the hospital, educating them on what we do and how we bring value. One of them didn't want to give me very many OR privileges either. It was lucky that I had an orthopedic surgeon on my side that helped fight with me. Then I got privileges, but I couldn't do my own H & P's. That was another fight that I had to persevere through until I got that as well. Anyways, I guess I'm just saying I'm not JUST a complainer.

We've gotten way off base with this thread lol