Archive May 2017 XVIII, No. 5

Coding & Billing: 5 Keys to Self-Pay Collections

When the patient is the payer, payment is required at time of service.

Brenda Zuiderveen

Brenda Zuiderveen, CPC


patient self-pay COLLECTING CO-PAYS With the increase of high-deductible health insurance policies over the last decade, providers throughout the country have seen a surge in patient self-pay.

It's estimated that 1 out of every 4 dollars spent on health care today comes directly from patients, a startling statistic that speaks as much to the surge in patient self-pay as it does to the challenge of running a surgical business office at a time when many patients need an interpreter to help them understand their high-deductible health insurance policies — and a mathematician to figure out how much they owe out-of-pocket for surgery.

It's never been more critical to your bottom line to get patients to pay their self-pay portion on the day of surgery. Remember: It's more difficult to collect from patients after service is rendered. Plus, you risk angering and alienating patients if you blindside them with a statement for what they owe out-of-pocket when they assumed that their health plan fully covered their surgery. That's where your business office team comes in, taking the time to educate patients about their insurance plan, verifying their benefits and eligibility, and then explaining those benefits so patients understand how much they owe before they show up for surgery. Here's what you'll need to do.

1Translate their insurance plan. Don't assume that patients understand the terms and conditions of their health plans, especially complicated cost-sharing ones that have, let's say, a $1,000 deductible, 20% coinsurance and a $50 set copay. It's confusing. Your collection rates will benefit when you help patients sort it all out.

2Estimate what they'll owe. Send patients a letter with an estimate, based on your contracted fees, of what they'll owe, and a reminder that payment is due at the time of service. It's important to emphasize that the dollar amount you quote is an estimate. For one thing, the patient could receive additional services on the day of surgery. For another, estimates are based on the patient's remaining out-of-pocket accumulators for their cost shares about 10 to 14 days before surgery. When verifying the benefits, let's say the patient has a $2,000 deductible on his plan, $1,000 of which has not been met. Your claim could have $1,000 applied to the deductible (if the allowed amount is higher than $1,000), then the remaining amount will have whatever co-insurance percentage the plan has (typically 10%, 20% or 30%) applied to it. That remaining $1,000 deductible is going to hit some provider's claim, but it might not hit yours if claims for other services go through the plan before surgery.

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