Surviving the Changing World
of Patient Collections
Presented to:
WellStar Business of Medicine Program
February 1, 2014
P...
Objectives
Understand how recent changes in
healthcare reimbursement affect the
practice bottom line.
Describe how you can...
Recent Changes that Affect
Patient Collections
• New health exchange plans
– Platinum, Gold, Silver, Bronze
– Greater liab...
Recent Changes that Affect
Patient Collections
• More high-deductible plans
Many patients have plans with $5,000$7,500 ded...
Overall Impact in Georgia
• As of December 28th, approximately 58,000 people had
enrolled in a plan through the exchange. ...
Overall Impact in Georgia
• As of December 28th, approximately 58,000 people had
enrolled in a plan through the exchange.
...
Overall Impact on Practices
• Practices must be more diligent in patient collections to
maintain a healthy bottom line.

•...
Overall Impact on Staff
• Front-line employees must be comfortable requesting money
from patients while maintaining a prof...
First Point of Contact
Front office employees are typically the first point of contact for patients.
This role is very imp...
Best Practice – Verify Insurance
• Verify insurance – no more than 2 days prior to appointment
per new ACA guidelines. Mai...
Recent Changes that Affect
Patient Collections
• New health exchange plans
– Platinum, Gold, Silver, Bronze
– Greater liab...
Establish Practice Policies
• Obtain demographics and medical insurance information at
time of appointment scheduling to i...
Establish Practice Policies
• All notes in the patients’ profile must be reviewed and
addressed by the front office. Indiv...
Best Practice – Time of
Service Collections
• Collect cash and co-payments and any portion of patient
balances at time of ...
Maximize Collections
Co-pay

$40

Total Visits/Month
(30 pts/day x 22
Insured
days)
Visits/Month

% Insured

Monthly Copay...
Maximize Collections
Average Patient
Responsibility

% Insured

$1,500

Total Visits/month
eligible for
deductible (5
Insu...
Odds of Collecting
After Date of Service

Prepared for WellStar Business of Medicine Program
February 1, 2014

Page 17
Establish Practice Policies
• Collect all balances at check-in
• Collect deposit or estimated amounts for patients with
co...
Establish Practice Policies
• *Require deposit or balance in full prior to procedures
whenever possible. Patient responsib...
Establish Practice Policies
• If patients object to payment in advance due to carrier policy, advise them
of the estimated...
Offer Convenient Payment Solutions
• Accept all forms of payment
• Convert checks to debit
• External financing
• Online p...
Best Practice – Patient Billing
• The patient collections cycle should be defined.
• Generally, patients should receive no...
Best Practice – Patient Billing
• The practice should set parameters within
the billing system to generate patient
stateme...
Establish Practice Policies
• Set parameters of payment plans:
No more than three installments for balances under x
dollar...
Establish Practice Policies
Staff must consistently monitor
payment plans. Establishing them
and not enforcing is not effe...
Set Patient Expectations
• Post policies in office and communicate directly with patients.
• Remind patients of past due b...
Educate Staff
• Prepare a listing of all plan products and practice status to
better inform staff. Advise patients at the ...
Educate Staff
• Ensure all employees are aware of policies.
• Advise them of tools available to them (manuals,
websites, c...
Monitor Data Entry
• Garbage in = Garbage out:
- Ensure staff are trained on important patient data fields.
- Monitor data...
Monitor and Communicate
• Communicate problems with management.
• Staff should share complex cases with each
other so that...
Contact Information

Lori A. Foley, CMA, PHR, CMM
Principal
lfoley@pyapc.com
Pershing Yoakley & Associates, P.C.
(404) 266...
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“Surviving the Changing World of Patient Collections”

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Many factors brought on by healthcare reform are affecting patient collections—new health exchange plans, newly insured individuals, more high-deductible plans, increased patient co-insurance responsibilities, and higher co-pays. Medical practices and their staff must become more diligent in patient collections to maintain healthy bottom lines. PYA Consulting Principal Lori Foley recently presented “Surviving the Changing World of Patient Collections” during the Business of Medicine Program at Kennesaw State University.

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  • Up from 6,800 at the end of November. Of these, 19% have enrolled in Platinim, 12% in Gold, 57% in silver, and 12% in Bronze. Others may have enrolled directly with insurance carriers if they were not eligible for a government subsidy. Additionally, HHS reports that an additional 30k+ qualify for Medicaid/Medicaid CMOs
  • If patient premium is late: 1-30 days, payer pays claim; 30-90 days, claims are pended for payment; 90+days, claims are denied and practice must collect payment from the patient. So patient may show active at the time of verification but if they don’t pay their premium, this could affect the practice’s ability to collect from the payer. Practices have a 2 days verification grace period. If insurance verification is done within 2 days of the visit, the practice can appeal to the payer.
  • Some plans offered on the exchange are outsourcing verification to other companies. So just because you have a BCBS policy, doesn’t mean you call BCBS to verify insurance. This will be insurance if your system only verifies basic information and you need more detailed information.
  • Impact of not collecting a co-pays over a 1 year period.
  • Impact of not collecting a patient responsible balances over a 1 year period.
  • “Surviving the Changing World of Patient Collections”

    1. 1. Surviving the Changing World of Patient Collections Presented to: WellStar Business of Medicine Program February 1, 2014 Presented by: Lori A. Foley, CMA, PHR, CMM www.pyapc.com Prepared for WellStar Business of Medicine Program February 1, 2014 Page 1
    2. 2. Objectives Understand how recent changes in healthcare reimbursement affect the practice bottom line. Describe how you can best equip yourself in the current environment to maintain high collection percentages Prepared for WellStar Business of Medicine Program February 1, 2014 Page 2
    3. 3. Recent Changes that Affect Patient Collections • New health exchange plans – Platinum, Gold, Silver, Bronze – Greater liability regarding patient responsibility if plan is subsidized • Newly insured individuals – Patients that have been previously uninsured may not understand the provisions of their plan or how insurance works in general Prepared for WellStar Business of Medicine Program February 1, 2014 Page 3
    4. 4. Recent Changes that Affect Patient Collections • More high-deductible plans Many patients have plans with $5,000$7,500 deductibles • Increased patient co-insurance responsibilities Patient co-insurance responsibility (after deductible) ranges from 20%-30% in most cases. • Higher co-pays Average copays range from $40 to $75. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 4
    5. 5. Overall Impact in Georgia • As of December 28th, approximately 58,000 people had enrolled in a plan through the exchange. However, others may have selected to apply directly with payers if they were not eligible for a subsidy. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 5
    6. 6. Overall Impact in Georgia • As of December 28th, approximately 58,000 people had enrolled in a plan through the exchange. • The enrollment deadline was extended to March 31, 2014. • Existing insurance benefits are changing overall to absorb the cost of expanding coverage. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 6
    7. 7. Overall Impact on Practices • Practices must be more diligent in patient collections to maintain a healthy bottom line. • Insurance verification is more important now than ever. Practices risk a significant portion of revenue by not doing so. • Patients and staff must be educated on the variety and complexity of plans. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 7
    8. 8. Overall Impact on Staff • Front-line employees must be comfortable requesting money from patients while maintaining a professional demeanor. Having the right people in these positions will be critical to the bottom line. • Depending on the practice specialty and resources, insurance verification may require more staff time. • More staff time may be required on the back-end to follow up and collect patient balances. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 8
    9. 9. First Point of Contact Front office employees are typically the first point of contact for patients. This role is very important as this sets the tone for the patient/practice relationship and is the starting point for the billing cycle. POINT OF CONTACT If patient demographics are not correctly entered, this delays the entire collections cycle. If practice financial policies are not enforced, patients will take notice and may become more “relaxed” in their payments to the practice. It is important to be welcoming and pleasant while also being firm on policies. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 9
    10. 10. Best Practice – Verify Insurance • Verify insurance – no more than 2 days prior to appointment per new ACA guidelines. Maintain evidence of verification. • Obtain pre-authorizations prior to appointment date. Know what procedures/services need authorizations. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 10
    11. 11. Recent Changes that Affect Patient Collections • New health exchange plans – Platinum, Gold, Silver, Bronze – Greater liability regarding patient responsibility if plan is subsidized • Newly insured individuals – Patients that have been previously un-insured may not understand the provisions of their plan or how insurance works in general Prepared for WellStar Business of Medicine Program February 1, 2014 Page 11
    12. 12. Establish Practice Policies • Obtain demographics and medical insurance information at time of appointment scheduling to include phone number for verification. • Nature of visit is also important for insurance verification • Detailed verification of insurance and benefits will be required. The practice should investigate potential resources such as PMS add-ins; 3rd party vendors (Availity, Freesia, etc.); registration at payer sites. • Patient should be contacted if anticipated services will not be covered or subject to co-insurance. All expected amounts should be communicated to patient PRIOR to appointment. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 12
    13. 13. Establish Practice Policies • All notes in the patients’ profile must be reviewed and addressed by the front office. Individuals responsible for appointment reminders and check-in/out must review patients’ information prior to contact and be prepared to address any issues. • Comments should be cleared from patient profile once issues are resolved to eliminate “noise” in the profile. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 13
    14. 14. Best Practice – Time of Service Collections • Collect cash and co-payments and any portion of patient balances at time of service. • Estimate patient responsibility for self-pay patients and require payment prior to being seen. • Understand what is considered Preventative Care (covered at 100%). Prepared for WellStar Business of Medicine Program February 1, 2014 Page 14
    15. 15. Maximize Collections Co-pay $40 Total Visits/Month (30 pts/day x 22 Insured days) Visits/Month % Insured Monthly Copay Quarterly $ Copay $ Annual Copay $ 5% 660 33 $1,320 $3,960 $15,840 10% 660 66 $2,640 $7,920 $31,680 15% 660 99 $3,960 $11,880 $47,520 20% 660 132 $5,280 $15,840 $63,360 25% 660 165 $6,600 $19,800 $79,200 30% 660 198 $7,920 $23,760 $95,040 35% 660 231 $9,240 $27,720 $110,880 40% 660 264 $10,560 $31,680 $126,720 45% 660 297 $11,880 $35,640 $142,560 50% 660 330 $13,200 $39,600 $158,400 Prepared for WellStar Business of Medicine Program February 1, 2014 Page 15
    16. 16. Maximize Collections Average Patient Responsibility % Insured $1,500 Total Visits/month eligible for deductible (5 Insured pts/day x 22 days) Visits/Month 5% 110 10% 110 15% 110 20% 110 25% 110 30% 110 35% 110 40% 110 45% 110 50% 110 Monthly Quarterly Annual Deductible Deductible $ Deductible $ $ 6 $8,250 $24,750 $99,000 11 $16,500 $49,500 $198,000 17 $24,750 $74,250 $297,000 22 $33,000 $99,000 $396,000 28 $41,250 $123,750 $495,000 33 $49,500 $148,500 $594,000 39 $57,750 $173,250 $693,000 44 $66,000 $198,000 $792,000 50 $74,250 $222,750 $891,000 55 $82,500 $247,500 $990,000 Prepared for WellStar Business of Medicine Program February 1, 2014 Page 16
    17. 17. Odds of Collecting After Date of Service Prepared for WellStar Business of Medicine Program February 1, 2014 Page 17
    18. 18. Establish Practice Policies • Collect all balances at check-in • Collect deposit or estimated amounts for patients with coinsurance/deductibles. Settle-up may be completed at check-out • Unless emergent, patients should not be seen if balance is not paid • Fees for no show appointments, forms, etc. • Self-pay discount Prepared for WellStar Business of Medicine Program February 1, 2014 Page 18
    19. 19. Establish Practice Policies • *Require deposit or balance in full prior to procedures whenever possible. Patient responsible amounts may be separated in 2-3 installments: 1st installment at time of scheduling 2nd (final) installment at pre-op 3rd installment (for high amounts) due within 2 weeks following procedure *Recent research has shown that some carriers are now advising patients not to pay prior to insurance claim processing (BCBS, CIGNA). Prepared for WellStar Business of Medicine Program February 1, 2014 Page 19
    20. 20. Establish Practice Policies • If patients object to payment in advance due to carrier policy, advise them of the estimated amount due and obtain their signature on a promissory note. Employees should attempt to obtain a credit card number for future billing at this time as well. • Employees will need to review EOB’s once payment is received and contact the patient regarding actual amount due. They should inform the patient that their card will be billed at this time and a receipt will be mailed to them. • If no card is on file, the patient should be notified that payment is due immediately. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 20
    21. 21. Offer Convenient Payment Solutions • Accept all forms of payment • Convert checks to debit • External financing • Online payments • Automatic payments Prepared for WellStar Business of Medicine Program February 1, 2014 Page 21
    22. 22. Best Practice – Patient Billing • The patient collections cycle should be defined. • Generally, patients should receive no more than 4 statements prior to being sent to collections. • Patient statements should not show the collections timeline (i.e., 0-30 day, 31-60 days buckets). This falsely indicates that the patient has several more cycles before they must pay. Alternatively, statements should have a payment due date. • Patients with accounts in collections should not be scheduled for an appointment prior to balances being paid in full. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 22
    23. 23. Best Practice – Patient Billing • The practice should set parameters within the billing system to generate patient statements at the time a patient responsible balance is created after insurance payment posting. Not doing so could significantly delay payment. • Once statements are generated, they should follow the normal statement cycle of the practice (i.e., statement every 30 days). Prepared for WellStar Business of Medicine Program February 1, 2014 Page 23
    24. 24. Establish Practice Policies • Set parameters of payment plans: No more than three installments for balances under x dollars No more than four installments for balances under y dollars Only allow payment plans for emergent or costly procedures. Otherwise, patients should be instructed to pay prior to procedure/visit. Practice should generally not allow more than six installments. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 24
    25. 25. Establish Practice Policies Staff must consistently monitor payment plans. Establishing them and not enforcing is not effective. Patients should be contacted within 1-2 days of missing a scheduled payment. This will reinforce to the patient that the practice is monitoring and will hold them to the terms of the established plan. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 25
    26. 26. Set Patient Expectations • Post policies in office and communicate directly with patients. • Remind patients of past due balances prior to appointments (utilize notes within system). • Consistently enforce policies. • Limit physician involvement. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 26
    27. 27. Educate Staff • Prepare a listing of all plan products and practice status to better inform staff. Advise patients at the time of registration of practice’s status with plan--participating, not participating, in process. • Employees must understand how to identify plans, especially with the addition of exchange plans. Most have an X in the identification number or have the metallic name as a part of plan name. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 27
    28. 28. Educate Staff • Ensure all employees are aware of policies. • Advise them of tools available to them (manuals, websites, cheat sheets, etc.). Prepared for WellStar Business of Medicine Program February 1, 2014 Page 28
    29. 29. Monitor Data Entry • Garbage in = Garbage out: - Ensure staff are trained on important patient data fields. - Monitor data entry errors. - Use a claim scrubber. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 29
    30. 30. Monitor and Communicate • Communicate problems with management. • Staff should share complex cases with each other so that experience is gained. • Monitor compliance with established policies and effectiveness. Prepared for WellStar Business of Medicine Program February 1, 2014 Page 30
    31. 31. Contact Information Lori A. Foley, CMA, PHR, CMM Principal lfoley@pyapc.com Pershing Yoakley & Associates, P.C. (404) 266-9876 www.pyapc.com Prepared for WellStar Business of Medicine Program February 1, 2014 Page 31

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