Sending patients to collections

[FreshDoc]

I work as an ophthalmologist in a relatively rural area, and some of my patients do not have a lot of options for doctors if they choose to "burn their bridges" by not paying or otherwise being dismissed. My staff sends all collection accounts for review to me, and I choose to send to collections or write off. I have a hard time dismissing patients I am actively treating, but I also don't want to be a sucker who doesn't get paid. Just wondering if you all use any criteria for sending to collections, or just your general thoughts on this topic. I have heard but don't know for sure that sending to collections doesn't net very much money in the end too. Thanks.

[Gamma Knives]

We don't send accounts to collections. My understanding is you don't get much money. Have you tracked much you get from ones sent to collections? I don't want to send my patients to collections. Not to mention it is a terrible look to send cancer patients to collections. We do require patients in arrears to meet with our financial counselor but do not fire patients on treatment.

I would suggest that you create a policy that your team can enforce rather than putting the burden on you to decide on a case by case basis. You probably already have enough stress. I imagine that you want to determine who has life or vision threatening situation but hopefully you can outline diagnosis or other factors that your staff can use in policy enforcement.

How much are you getting from insurance? We try to collect co-pays as it adds up to a lot. However, for some patients, we are ahead providing treatment and only getting what the insurance pays. Due to the cost of cancer treatment, nearly all of our patients are exceeding their out of pocket maximums. So, most of our revenue comes from insurance. Your practice revenue may be very different.

[Kamban]

I looked into it since I am solo and the hospital sends everyone to collections ( even me, when they did not even send the bill to the insurance)

1. You cannot discriminate and send one patient to collection and not another. It can land you into trouble if you play favorites. Either send all or none.

2. Sometimes threat of collection might do the trick.

3. Collect as much as you can upfront. Check if they have met deductibles and if not, find out and make them pay it before you provide service.

4. I have no problem with service being unpaid, but I don't want to provide infusions where I buy the medications with my money and not have that paid. I usually don't allow it but sometimes things slip through.

5. I now don't see patients unless they have cleared their balance. So at the least I only am out for one visit or service. It is miraculous how patients who say they have no money manage to find the $250 to clear their balance so that they can see me one more time.

6. Collection agencies get 30% or more and collect the easy money. I have not used them, after hearing the experience of my colleagues.

[Random1]

You should see the patients or discharge them, but I would not do anything in between , like not seeing them until they pay their balance because you might end up with patient abandonment issues , especially if they do not have other local choices. I would formally discharge them by proper means and then decide if you want to see them back after bills are paid.

Everyone is in a different situation in life and many are less fortunate them we are. I would help them out any way you can, but if someone does not offer anything to help settle their account , I look at as if they dont value my services. Someone can spend $300/month on cigarettes but can not sent you a check for $20 ?

[FreshDoc]

This advice is helpful, I joined a practice that was already doing this "case by case" evaluation, and I did not realize that it could get us into trouble. I am going to talk to our revenue cycle admin and OMIC (ophthalmology malpractice) and see if we need to change some policies, thanks.

[MPMD]

I looked into it since I am solo and the hospital sends everyone to collections ( even me, when they did not even send the bill to the insurance)

1. You cannot discriminate and send one patient to collection and not another. It can land you into trouble if you play favorites. Either send all or none.

2. Sometimes threat of collection might do the trick.

3. Collect as much as you can upfront. Check if they have met deductibles and if not, find out and make them pay it before you provide service.

4. I have not problem with service being unpaid, but I don't want to provide infusions where I buy the medications with my money and not have that paid. I usually don't allow it but sometimes things slip through.

5. I now don't see patients unless they have cleared their balance. So at the least I only am out for one visit or service. It is miraculous how patients who say they have no money manage to find the $250 to clear their balance so that they can see me one more time.

6. Collection agencies get 30% or more and collect the easy money. I have not used them, after hearing the experience of my colleagues.

no in PP and don't do billing but this seems like good advice to me

[SerrateAndDominate]

I'm not involved much in the billing aspect of things at my big multispecialty group, but I remember our CFO saying they rarely do collections for the reasons listed above. Essentially, they use a financial services rep to come up with a payment plan. As long as someone is paying something each month towards their balance, they are still seen. Payments are as little as $10 per month.

Agree with others about having a standardized approach so you aren't somehow twisted into a "discrimination" label no matter how benevolent your intentions are.

[FreshDoc]

I had a chance to review what our malpractice recommends: it seems as if we are doing things the recommended way – “Obtain physician approval before sending a patient to collections.” But this still seems dangerous to me. We send out letters threatening collections on a third attempt, but then it finally comes to the physician so we can make the determination if we are at risk for abandonment litigation if they have an acute problem. When dismissed, the letter states the risk they are taking by not seeing a doctor, and offers assistance in transferring their records, etc.

I like the idea of not sending to collections, but rather simply not seeing them again until the balance is cleared. Might make some changes to our SOP.

[Kamban]

I had a chance to review what our malpractice recommends: it seems as if we are doing things the recommended way – “Obtain physician approval before sending a patient to collections.” But this still seems dangerous to me. We send out letters threatening collections on a third attempt, but then it finally comes to the physician so we can make the determination if we are at risk for abandonment litigation if they have an acute problem. When dismissed, the letter states the risk they are taking by not seeing a doctor, and offers assistance in transferring their records, etc.

I like the idea of not sending to collections, but rather simply not seeing them again until the balance is cleared. Might make some changes to our SOP.

I have varied staff and patients - white, AA, Hispanic, Asians, young, old, well off, barely making it and so on. If I have to make decisions on individual basis, I will usually rub off one patient group or staff the wrong way and this can later land me in legal or other troubles. So I have the standardized policy for all patients. If they set up a payment plan and stick to it I can continue to see them.

The major exemption I make is obviously a very poor patient who barely has any money for food and basic necessities who has to meet his copay. Usually occurs in the "Medicare with no supplement" setting.. I see them and consider the 20% uncollected as non-deductible charity.

The best way to avoid this is to have a plan of how to collect upfront. Having the billing person check on the copay and how much of the deductible has not yet been met, even before the patient comes to the office. Ideally a day or two before. And try to collect it at check in before they see you. A less desirable option would be to pay at check out before they get their next appointment date but somehow a good number of them "have forgotten their purse or checkbook or credit card" miraculously by that time, having seen the doctor. Those can end up as long overdue unpaid amount.

[TXDoc21]

We collect copays/expected costs upfront before I see them. They even call the patients to let them know what they will be collecting before they get there. That minimizes the sticker shock when they walk in. The billing people check their insurance ahead of time. It really minimizes a lot of this issue although some can still be missed.

[oocyte_]

I have varied staff and patients - white, AA, Hispanic, Asians, young, old, well off, barely making it and so on. If I have to make decisions on individual basis, I will usually rub off one patient group or staff the wrong way and this can later land me in legal or other troubles. So I have the standardized policy for all patients. If they set up a payment plan and stick to it I can continue to see them.

The major exemption I make is obviously a very poor patient who barely has any money for food and basic necessities who has to meet his copay. Usually occurs in the "Medicare with no supplement" setting.. I see them and consider the 20% uncollected as non-deductible charity.

The best way to avoid this is to have a plan of how to collect upfront. Having the billing person check on the copay and how much of the deductible has not yet been met, even before the patient comes to the office. Ideally a day or two before. And try to collect it at check in before they see you. A less desirable option would be to pay at check out before they get their next appointment date but somehow a good number of them "have forgotten their purse or checkbook or credit card" miraculously by that time, having seen the doctor. Those can end up as long overdue unpaid amount.

Question, if patient's cannot afford the copay are they turned away or still seen?

[Cubicle]

We check patient's insurance details before every single visit. If we are unsure about anything, whether the deductible applies, whether the insurance is actually active, we tell the patient they need to leave a deposit. If they object we tell them to contact the insurance & we will see them after.

Otherwise we collect copays upfront. If I know the patient well, & they usually never forget their copay, I'll see them if they say they'll bring it later. I never ask, I let them offer. New patients or not good "credit" with me, I tell them we will reschedule them for another time if they don't want to go to the atm or bank both 1 block away.

We let balances get to $100 before we tell patients they need to bring their balances to zero before any more appointments. Mostly the coinsurances at that point. Knock on wood, very few people abscond this way.

If the insurance decides to deny even though we checked, we tell them patients to contact their insurance so we don't have to send the patient themself a bill. We also tell them "to avoid any more bills you might have to pay, we will reschedule your appointments until you speak with your insurance". Knock on wood that seems to work pretty well.

Paying & non paying patients always have the right to sue me. Barring something acute or life threatening, every patient has to contribute to my malpractice insurance premium.

[ENT Doc]

You should see the patients or discharge them, but I would not do anything in between , like not seeing them until they pay their balance because you might end up with patient abandonment issues , especially if they do not have other local choices. I would formally discharge them by proper means and then decide if you want to see them back after bills are paid.

Everyone is in a different situation in life and many are less fortunate them we are. I would help them out any way you can, but if someone does not offer anything to help settle their account , I look at as if they dont value my services. Someone can spend $300/month on cigarettes but can not sent you a check for $20 ?

This is good advice re: abandonment, legally speaking. The best time to collect is up front. Those failing to do so and relying on patient good will are misunderstanding what's going on out there.

[Kamban]

Question, if patient's cannot afford the copay are they turned away or still seen?

Depends.

If it is one time, and he /she has paid the copays in the past we see them. If they are very poor and have just Medicare with no secondary I will see them. But someone who has a good insurance and has a high copay or is being seen the first time, they are asked to reschedule the visit for a later date and bring their copay. If they can't do that then they can choose the specialists at the hospital where you might get seen without copays but also be charged exorbitant amounts for the same service.

Copays have inversed in the past 2 decades. When I started PP, copays used to be $10 or so and my visit would be $80, so I would get at least $70 from the insurance and the $10 lost was no big deal. Now most insurances have $60 copays to see a specialist but still pay only $80 or less in spite of all the inflation in the interim 20 years. If the patient now does not pay their copay I get only $20 which is way below my overhead even for an empty office. I can't afford that.

[molar roller]

In a dental practice, it's very common to have patients on in-house payment plans. Some default on their agreements, owing us hundreds or thousands of dollars. It happens rare enough that it's still worth doing for vast majority of patients, but obviously annoying when the patient just disappears with a $2K balance.
Collection agencies have been pretty useless. Their efforts are rarely more than robocalls. In almost 20 years, I'd say we collected less than ten cents on the dollar, and a third of that went to the agency. Not really worth doing.

OTOH, small claims courts have been more useful. We don't use them often, maybe once every 3 years or so we'll collect a bunch of deadbeat accounts of $750-1000+ and file small claims suits. Patients never show up, we get default judgments, and every once in a while, several years later, the patient pays. Not much gain either, but better than nothing.