Practice Management Alert

Addressing a problem means you may have to charge when patient didn’t expect to pay.

Under the Patient Protection and Affordable Care Act (PPACA) that became law in 2010 your practice must provide preventive care visits at no cost to the patient or family. But when a patient who comes in for a well checkup but at the end of the encounter the patient says “Oh by the way” and mentions a problem that the provider then reviews, everything changes. 

In the article “Solidify Your Preventive + Problem-Oriented Coding Knowledge” on the cover, you learned how to code for preventive and problem-oriented services during the same encounter. But what about the impact on your patients?

While preventive visits are not subject to a co-pay, coinsurance or deductible, problem oriented encounters are different. So patients who come to your practice expecting to leave without paying any money out of their pockets may suddenly owe you money. If you don’t have proper policies in place to handle these situations you may face collections problems and upset patients. Follow these three steps to avoid these awkward situations and keep patients smiling. 

1. Explain Your Contractual Agreement

Tell the patient that you have a contractual agreement with the insurer that requires you to report problem/sick visits when you perform them. Explain that if they have the issue addressed while they’re already at your office, you are legally required to submit the claim to their insurer for the service.

Keep in mind: Some payers may not reimburse for office visits on the same day of a well check. You may need to make patients responsible for this portion of the payments. Before adopting this method, verify that your major payers consider the office visits noncovered, rather than bundled. The contract must also allow you to balance bill patients for noncovered services.

2. Consider An Educational Brochure

Many practices have been able to quell this issue by creating a short one-page fact sheet about billing that explains the difference between a preventive medicine visit (such as a well child check and a vaccine) and a problem visit. The sheet can explain what each visit costs, what the PPACA covers (and what it doesn’t), and which visits are exempt from copays and deductibles. 

Having such an educational sheet not only explains the billing process to the patient, but it also shows that you aren’t singling that patient out for a carved-out payment along with the wellness visit. Particularly in cases when patients have high copays and deductibles, they can sometimes think you are targeting them with a “surprise” problem-focused service, when in reality the brochure can explain that this is fairly common and can show them what their rights are.

3. Offer to Have the Patient Return Later

In cases when the patient is getting a no-cost service and you foresee also billing a problem visit during the same session, explain that the problem-oriented visit will prompt a copay/deductible so the parent knows about it upfront. 

If a patient’s sick condition requires a significant and separate E/M service from the well check, you could suggest the patient return for another visit. You can either reschedule preventive medicine services or the problem-oriented encounter. The downfall is that you have to weigh the inconvenience this could cause the patient and the negative public relations this could generate.

In cases like a deep laceration or something else that’s urgent, the option of coming back another day might be impossible. However, if the parent wants to discuss the patient’s ADHD, you should offer for them to come back another time because that problem-focused discussion will turn the wellness visit from a “free” encounter to a paying visit.

Of course, when the parent returns, they will still be subject to the deductible and copay, but at least they’ll know about it and be able to make the decision of whether they want to pay it now or pay it later.

Check The Example

In the companion article on the cover, you read the example of a six-year-old patient presents for a wellness visit, but the patient’s mother is concerned that the child also has been complaining about ear pain after swimming lessons. 

In this case, the patient presented for a “free” physical but the doctor discovered a significant problem that was separately evaluated during the visit. You’ll report the preventive medicine code and the appropriate E/M code (such as 99212-25) as noted in the other article. 

This visit will prompt a co-pay due to the 99212 charge. Therein lies the issue that your front desk personnel will have if the parent balks at the payment that is now due at the visit. If you face such issues with your patients, apply the three tips above can ensure that these patients still leave your practice satisfied, despite having to pay for a non-wellness service.