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Why it is increasingly critical to collect patient copays, deductibles and coinsurance.



Member policies are shifting


We are seeing much higher deductibles for in and out of network policies. This means that the client will need to pay a much higher amount before the insurance will even pay $1. It used to be common practice to find policies that paid 80% after the deductible was met, leaving the patient responsible for 20%. This has changed significantly, as many payers are holding their members responsible for a greater percentage of the allowable.


The average out of network policy reimburses 60% and leaves the member responsible for 40%. This means that unless your facility is collecting deductibles, copays and co-insurance, you will see a decline in revenue.


What this means for your facility:


It is critical to have the financial conversation with your client before they admit to your facility. If the deductible hasn't been met, collect it up front or set your client up on a reoccurring payment plan - autopay, if possible. Autopay can be a great way for medical facilities to increase their gross revenue. By setting up an automated payment system at the time of admission, you are more likely to receive payments well after the client leaves your care. This will help increase the amount of payments a facility gets each month, as well as reduce the amount of time and manpower needed to manage

payments. Additionally, autopay can help to reduce the amount of financial stress for patients that unexpected medical bills may cause. Overall, this transparency will likely lead to more satisfied customers and more referrals.


Staff Training:


Train your admission staff to feel confident having these financial conversations. If you own a mental health or substance use facility, your admission staff likely has thorough training in stabilizing, guiding and supporting the potential client. There is likely a comfortability in the intake process and managing different behavioral issues. Ideally, your admission staff will feel equally as comfortable discussing the client's financial options and expectations once the insurance claims finalize.


In order to provide a high level service, you need to maintain your revenue stream - Have the financial conversation.


Does your staff understand how to calculate a patient's financial responsibility?


If you staff is going to feel comfortable talking about money, they first need to understand how to read an explanation of benefits. It sounds like a no-brainer but this process is more difficult than it sounds for those who do not have proper training.


After running a VOB, the admission staff should read the benefits and explain the process to the patient in a clear, concise way, and provide any available options. If the patient is unable to afford the full amount of their deductible or coinsurance, you may offer a payment plan. It may also be helpful to provide additional resources to the patient, such as contact information for any financial assistance services or additional insurance coverage options. Ultimately, having an open and honest discussion about billing and insurance will ensure that the patient is able to receive the care they need.


Create a Standard Policy and Procedure

This is the best way to get your admission staff comfortable talking about money. If they know the different options for the client on the spot, it will be quicker and simpler to seal the deal. The policy should ensure that all patients are aware of the payment options and that they have a clear understanding of what is expected of them. The policy should include a detailed explanation of their benefits, the fees involved, and any other payment options. This will ensure that no patient is left unaware of their payment obligations, and that they are able to make informed decisions about their treatment.


In addition to the change in policy reimbursement, many in and not out of network providers are requiring that the provider collects the member's copay, coinsurance and deductibles, and will flag accounts that do not comply. Last year, we saw requests from both United Behavioral Health and Cigna, asking for proof that our out of network facilities collected patient responsibility. Although there were attempts to collect from clients, according the the payers, the attempts were insufficient. They took this one step further by requesting money back in the amount of patient responsibility.


While we are fighting this practice legally, in the meantime, it has created a delay in payment by requiring us to send in medical records and appeals in order to get the claims paid.


Steps to Avoid Audit Issues:

  • Document your specific financial agreement with each client.

  • Update your admission package - Create a standard form that outlines what the patient's expected financial responsibility is and make sure that it is signed by the client and facility administrator. Save it to your EMR.

  • Document your collection attempts: include dates that each statement was sent to the patient, copy of the void check or receipt from the credit card transaction. If you have a collection team, ensure that they are taking notes of each time they call and the outcome of the call.

  • Utilize the No Surprise Billing Act: The no surprise billing act was created to eliminate surprise billing when clients utilize out of network providers. According to the act, facilities can gather an expected explanation of payment for the client BEFORE treatment begins. Although there are some kinks to be worked out of this new legislation, it should be utilized by providers.



Collecting copays, deductibles and coinsurance will at the very least improve your bottom line, but it could also save you from refund requests, payer audits, flagged accounts, and even having your in-network contract canceled.


We are seeing payers at both the in and out of network level require that providers are collecting the patients responsibility and impose harsh actions for those who are not aligned with their desired process. This is an evolving story and will be updated as more information is gathered.


If you're looking for medical billing services to keep your facility running smoothly, don't hesitate to reach out to us today. Our team of experienced professionals are here to answer your questions and provide you with the best solutions for your needs. We look forward to hearing from you and helping you achieve a streamlined and successful medical billing process.


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