Finance is a touchy subject, but in health care the discussion of money may be particularly sensitive. Yet as primary care clinics struggle to stay open, many practices are implementing policies that they hope will generate revenue (even if that just means collecting the fees they are owed in the first place).
More practices are starting to request a credit card number from patients in order to “hold” an appointment; if a patient becomes a no-show, the office reserves the right to charge a fee to the card. (Some even ask for a down payment upfront.) Having this information on file, along with a signed consent from the patient, also makes payment collection easier.
While such policies are standard in the hotel industry and common among restaurants, in a health care setting they engender mixed feelings. Health care, after all, is a human commodity—but at the end of the day, it is also a business.
“The truth is, you cannot provide services without making money,” says Barbara C. Phillips, MN, NP, who in addition to her clinical practice provides business consulting services to NPs. “If you have a business—and all clinics are businesses—you have to generate enough revenue, enough profit, to cover your overhead, so that you can pay your staff, so you can grow your business and provide more services.”
WHAT’S YOUR (CREDIT CARD) NUMBER?
Along with helping to improve patients’ health, getting paid for the services they provide is the goal of every clinician. For one thing, it helps their own bottom line (even if not all primary care providers drive Jaguars, as some patients seem to think) and for another, it allows them to stay in business, where they can provide more services to more people in need.
But—particularly in tough economic times—getting paid is not always easy. Some patients really are in financial straits, yet desperately need health care, whereas even those who are insured may balk at the idea that they owe money out of pocket after a bill has been adjudicated.
How clinicians handle money matters depends on the type of practice they have and their comfort level with implementing different policies. For example, at Deerpath Primary Care, a mid-sized private practice located on Chicago’s North Shore, collections are handled by Athena Health. Patients provide a credit card number at the time of their visit and are asked to sign a consent form giving Deerpath permission to charge the balance of the bill to that card after the claim has been adjudicated.
“As it turns out, a lot of people like this, because they don’t have to do anything,” says Lisa Dandrea Lenell, MPAS, PA-C, who is Director of Operations as well as a clinician at Deerpath. “They don’t have to get a bill in the mail; we just send them a receipt.”
Patients can choose from a number of ways to be notified about pending bills—phone, email, texts, or messages through a secure Web portal. Through the portal, patients can also make or cancel appointments and set up a reminder service to notify them of upcoming appointments. They are also informed that 24 hours’ notice of cancellation is required or a $50 no-show fee will be assessed.
“We don’t often add it on,” Lenell admits. “But if you’ve done this a couple of times, and we know that you were told about the $50 fee, then we’ll add it.”
By contrast, Joy Elwell, DNP, FNP-BC, FAANP, owns her private practice in Scarsdale, New York, and does not have credit card policies in place. Her electronic medical record system sends automatic reminders to patients via email—one a week before the appointment and another the day before—and her staff follows up by phone the day before the appointment as well.
“If patients still forget—if they forget once, well, everybody forgets now and again,” Elwell says. Her staff calls to check on the patient and reschedules the appointment. “If they do it twice—if they break two appointments in a row—then we tell them that they cannot have an appointment. They can come in and be seen, but they will have to wait for an opening and we will fit them in when we can.”
Elwell’s reason for not taking “reservations” with a credit card or assessing no-show fees is simple: On occasions when she has been asked for her information, she hasn’t liked the way it made her feel. She knows other practices that have such policies and has been surprised to learn that patients return to those practices despite the request for credit card information.
“I don’t think it will be a deterrent to seeking health care,” she says. “But I think it sets up an adversarial relationship between the patients and the provider.”
BUY-IN FROM PATIENTS
The first steps toward introducing such business practices include assessing the need for improved collections—is getting paid even a problem for you?—and determining what types of fees or policies you can legitimately implement. Many insurers—most notably, but not exclusively, those that are government-funded—prohibit health care providers from collecting money from patients outside the terms of the contract.
Furthermore, as credit card companies seek to reduce risk for fraud, your merchant accounts may take issue with holding a patient’s credit card information and charging it “remotely,” as opposed to swiping the card at the time of service.
But most important, if you decide to introduce these policies, is getting buy-in (no pun intended) from patients. The #1 concern will be the safety of their information: how it will be stored and how it will be used. (Your billing software vendor or merchant account may have solutions for you.)
“People often don’t want to leave their credit card [with you]—although good grief, Amazon has everybody’s credit card!” says Phillips with a laugh. “But you want to make sure you have a signed agreement on hand giving you permission to do this, and then a way to communicate with patients that you have carried this out and charged their card.”
Patients also appreciate knowing that you will work with them. Payment plans may be a suitable option for patients who have difficulty paying an entire bill; even $10 a month, as Lenell says, is a sign of “good faith. We just want to know that you don’t think our services are worth zero.”
The collections methods of the past—threatening letters and phone calls—did little to engender goodwill among patients who were made to feel like criminals over $5. “What we’ve said is ‘Tell us how you would like us to work with you, so that you can be a good patient and we can be good providers, and everybody is getting what they wanted out of the service,’” Lenell says. “[But] if patients want the ‘luxury’ of that comfortable place where you go in and everybody knows your name and you feel welcomed and cared for, they have to pay their bills.”
In larger practices, it may be easy to separate the financial from the clinical realm—the health care provider can direct patients to the office manager—but in smaller offices, the clinician/owner is where the buck stops. Elwell, for one, does not discourage patients from discussing the financial aspects of their care with her.
“If we’re really going to be partners in health care,” she says, “then that’s a significant part of it: the ability to pay for it. It’s a fact of life; to push it off or ignore it doesn’t work.”
Allowing patients to set up payment plans, ordering tests judiciously to reduce out-of-pocket costs, and directing patients to low-cost care options whenever possible are some of the ways clinicians can help patients reduce financial burdens—and perhaps ensure timelier payment for themselves.
“I don’t want to sound like a Pollyanna,” says Elwell, “but I really find that when you take good care of people and try to work with them and the resources they have, it usually works out in the end.”