Practice Management Alert

Question: An oversight at the front desk occasionally results in our office seeing a patient whose insurance company we are not a provider for without first clarifying this to the patient. In these situations, how liable is the patient for the bill? Can we bill even if the patient claims he was uninformed and would not have pursued care with us if he had known?

New York Subscriber

Answer: It's all written down in the insurance contract, and the patient is ultimately responsible for knowing the terms of his own insurance. Many practices struggle with the question of ethics, however. You may wonder how patients can be expected to understand their insurance information when it can be so confusing that even trained front-desk staff slip up once in a while.      
       
Consider all the ways to catch this type of problem before the patient is seen. "It really is the responsibility of the front-desk personnel," says Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J. A lot of practices have started preregistering their patients for this reason. When a patient calls to schedule an appointment, one of the first questions asked should be what type of insurance he has. If the patient doesn't know, you have a problem. You may want to suggest that the patient call back to finish scheduling once he has specific insurance details.
 
When your office calls to remind the patient of his upcoming appointment, verify insurance coverage and be sure to tell him to bring insurance information, the copayment, and a referral if needed. When the patient checks in, verify his insurance information once more. This may seem repetitive, but it's the best way to ensure you get the money you deserve. 
      
Some billers suggest that you keep a simple flow chart or spreadsheet at the front desk that lists all insurance companies your practice contracts with and other relevant information for each company, including co-pays and if referrals or authorizations are required. The chart should be made well known to all front-desk staff and kept in an easily accessible spot. Depending on how large your practice is, you may want to have someone at the front desk trained specifically in insurance matters to be able to assist with difficult or confusing situations.
 
Even when you're making all possible efforts to prevent patients with improper insurance from being seen, one can slip by. If this happens, "you've got a couple of choices," Brink says. First, she says, try billing the patient's insurance. If your practice doesn't participate, the insurance company will either deny the claim, put it toward the deductible, or pay the patient.
 
When a patient gets paid, he obviously owes you whatever money he got. If you still have a remaining balance and the patient refuses to pay, you must decide how worthwhile it is to pursue collection. If it's a relatively small balance, "it's going to be a lot easier and more efficient for you to write it off," Brink says, because otherwise "you're going to end up sending that money to a collection agency." If the balance is large, however, it's probably worth the hassle to pursue payment.

 - Reader Questions were prepared with the assistance of Wayne Miller, founding partner of the Compliance Law Group in Los Angeles; Kathy Pride, CPC, CCS-P, with QuadraMed in San Rafael, Calif.; and Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J.