Patient Billing Challenges: Frequently Asked Questions

It is appropriate to seek reimbursement for services that were rendered prior to a patient’s death. The practice can determine if it wants to pursue any amounts that are the patient’s responsibility based on several factors—including the amount of the outstanding balance or the estate’s ability to pay. If the family is dissatisfied with the patient’s care, the practice should also consider the possibility of adverse social media postings or the potential for the family to pursue a professional malpractice action or submit a complaint to the applicable state licensing agency.

Have administrative staff talk with the patient to investigate why the bill has not been paid. This will allow you to learn if the patient is dissatisfied with the care while avoiding the possibility of undermining the practitioner-patient relationship. After the discussion has occurred, you can consider alternative financing options, including a monthly repayment plan or the possibility of submitting the outstanding bill to collections.

It is helpful to have a written document summarizing the practice’s policy on financial matters that you give to each patient during the initial visit. A healthcare practitioner has the right to expect payment for services rendered. The practice should have a policy that is consistently applied in a nondiscriminatory fashion. Often, signage at the reception desk and a disclaimer posted on the practice’s website indicating that payment is expected at the time of service are appropriate ways to notify patients in advance of treatment. If a dispute subsequently arises, remind patients that they received a copy of your policy at the time of the first visit. It makes handling nonpayment situations easier and limits the potential for miscommunications that may lead to adverse consequences.

If you decide to terminate the patient relationship for nonpayment, you must follow a formal process that includes giving the patient proper notice of your intended course with an assurance that the office will provide treatment for emergencies in the interim. For more information, read our article “Terminating Patient Relationships.”

Yes, as long as the patient is not seeing you based on a referral from an emergency department (ED) where you were on call when the patient was seen. If that is the case, determine the hospital’s requirements as established in its medical staff bylaws as well as facility rules and regulations. You must follow those requirements. Find additional information in the following resource: “Healthcare Practitioners and On-Call Duties: Top Questions on Liability Risks.”

At a minimum, it is likely you will be required to see the patient at least one time to determine status and whether the patient has an emergency medical condition that qualifies under the Emergency Medical Treatment and Labor Act. If the patient needs emergent treatment, you will likely be required to provide care regardless of the patient’s ability to pay, although you can ask for payment or payment arrangements.

If the patient did not come to you as a result of ED call coverage and you have an established policy of not accepting patients who cannot pay, you can refuse to establish the relationship. For future reference, document your policy in a written office protocol that is maintained in an administrative file, complete with the date it was created and any subsequent revisions. Give potential patients a clear statement of your practice’s financial requirements when they make an initial appointment for treatment. In addition, posting a notification on your practice website helps communicate the policy in advance and helps to avoid any subsequent disputes or misunderstandings.

Potential patients who are not aware of your financial requirements may delay making other care arrangements while waiting for an appointment with you. If the patient then arrives for an appointment and you decide not to accept him or her for financial reasons, your decision may appear questionable if the patient is injured by the subsequent delay in receiving care.

Having the biller check the status of coverage before a patient arrives for an appointment can expedite your decision about whether to accept an individual as your patient.

Consider including a disclaimer regarding the practitioner-patient relationship on the practice website and on data collection tools (e.g., preliminary healthcare and insurance questionnaires). The disclaimer should state that the practice does not deem an individual seeking treatment to be a patient until a preliminary assessment is concluded and the individual has been notified about being accepted as a patient. Similarly, advise prospective patients at the outset that simply making an appointment or returning a completed health questionnaire does not automatically trigger the relationship.

Third-party payers frequently ask the following questions:

1. Was the care medically necessary?
2. Was the service delivered as evidenced by the patient’s records?
3. Is the billing code being utilized commensurate with the care the patient needed and actually received?

Auditors rely almost exclusively on the contents of the patient record to make those determinations. Accurate and timely documentation is, therefore, critical for a healthcare practitioner to obtain appropriate and prompt reimbursement.

The following strategies are effective ways to defend against patient surprise, misunderstanding, or dissatisfaction:

• Exercise care in patient selection.
• Establish reasonable patient expectations and keep the lines of communication open.
• Manage the practitioner-patient relationship by having individuals under consideration for becoming patients execute a Conditions of Treatment Agreement at the outset of the affiliation. (For more information, read our article “Proactively Manage Patient Expectations With a Conditions of Treatment Agreement.”
• Post your requirements on the practice website.
• Provide and document thorough preoperative informed consent that is consistent with community standards and incorporates the process of shared decision making.

If you are confronted by a dissatisfied patient who asks for compensation, contact your patient safety risk manager for help in evaluating the situation from potential professional liability and regulatory compliance perspectives. Depending on the circumstances, a prompt referral to the Claims Department of your professional liability insurer may be indicated to complete a notice of first report and help to preserve your procedural and substantive rights.

In some situations, making a concession at an early stage in the process may be viewed by the patient as a courteous and conciliatory gesture that may prove instrumental in avoiding a claim—or, ultimately, in presenting a compelling defense in the event of litigation. Other situations may warrant the use of a Release of Claims form. Payer-provider agreements, as well as CMS conditions of participation, often specify the circumstances under which a refund or waiver of some portion of a bill is permissible.

Credit card customers can always request that a charge be questioned. Normally, when this situation occurs, the credit card issuer will open an investigation into the disputed charge. During the inquiry, the card issuer may withhold payment of the amount in dispute.

Healthcare practices must exercise caution when interacting with credit card companies to ensure they do not violate patient confidentiality required under federal and state privacy laws. For patients who prefer to pay by credit card, one approach before rendering services is to require the patient as a precondition prior to treatment to execute an authorization to release protected health information (PHI) to the credit card company if it becomes necessary because of a subsequent dispute. In the event of a billing controversy, the PHI authorization will allow you to release the minimum necessary information under applicable disclosure laws to the credit card company without fear of regulatory or administrative reprisals.

Some commercial credit companies hold the practitioner responsible if a patient defaults on a payment. Before using a commercial credit company, read the contract carefully to make sure you won’t be liable for a patient’s outstanding balance, and consider consulting your corporate or personal counsel for guidance.

Be aware, too, of your state’s consumer protection laws regarding lending and disclosure, and make sure that your patients understand the terms and conditions of the financing.

Your bank or professional society may be able to help you locate a commercial credit company that specializes in these types of arrangements.