Home Forums Discussions General Discussion The Non-Paying Self-Pay

I have a patient I saw for an auto accident coming in tomorrow. He had 5 visits with my last year and the insurance did not pay. He owes me 1200 dollars that is going into collections. He has made an appointment with me tomorrow. I called and told him I do not want him going into deeper debt, but he says he wants to come in anyway. Because of the legal problem with abandonment, I feel I have to see him even though I won't get paid. Any advice on these situations?

Well, there is certainly no law at least in Maine as to how many days you have to give someone without its being abandonment based on there health. For instance, I may have to give 60 days if they have really bad asthma and cardiac problems but only one day if they are the picture of health.

People always have in their head that it is 30 days automatically. Now, I know you aren't necessarily looking to dismiss him, at least not at this point. I would see him one more time and explain you can't continue to see him any longer. Have a letter of dismissal with 30, 60 or how many days. You could talk to your liability insurance or fire an email to your attorney. My attorney is awesome when it comes to stuff like this.

You are stuck for tomorrow. Here in Alaska you need to offer at least emergency care for 30 days after notice of termination of care, which needs to be done in writing, hopefully certified mail. We terminate care for a number of reasons, including non-payment without some sort of plan in place (and we are WAY liberal about that.)

We offer emergency care. We call the ED for them. It's even in the letter. I am not seeing someone that isn't paying me and I don't want to see. I doubt it is emergency care anyway.

Is the bad debt due to the patient not paying their copayments and/or deductibles or the insurance company not paying anything? Did the insurance flat out deny the claim? Has your biller talked to the insurance company reps? Or is this solely based on EOB's?

Personal injury can be frustrating b/c the claims don't pay for a long time. However we always end up getting paid eventually, but not until the case is closed. I have some personal injury claims that were open 3-5 years. Once they settled in court we got paid. Sure it's frustrating to see the unpaid amounts going up and up, I completely understand. But we get paid.

You are stuck for tomorrow, no doubt. Not wise to refuse to see the patient. In the future you might consider a policy whereby you don't do personal injury claims. Perhaps you refer all these cases to a colleague who doesn't mind dealing w/ the lawyers.

When sending patients to collections, it is wise to include with the standardized letter that says "your unpaid balance is being sent to collections" something to the effect that "we will not provide medical care on your behalf until the unpaid balances are settled." This closes to the door to the scenario which you are facing tomorrow....bad debt coming back for free care.

BoonDoc, are you the PCP? Sole treating physician?
If not, then patient abandonment takes on a new flavor; you can provide recommendations and records to his PCP.
I have a different slant: I belived that in a non-emergency, you can demand payment up front if he truly is the responsible party. If he declines, you can not be forced to give away your time and services = you have a right to expect compensation for your services. You may need to see him just enough to determine if he truly does not have an emergency, but you are not bound by EMTALA as hospital EDs Are
Just need to CYA with 30d notice/Rx's, preferrably cretified letter. (in Calif, 15 days required by the Medical Board)
Your conundrum appears to be that an appt was made. Still you have a right to be paid, and just agreeing to an appt should not commit you to giving away free medical care, IMNTBHO

My first thought was why is he seeing an accident victim without getting the money from the patient up front? My experience with MVA's or falls on others' property or whatever that are filed through a liability insurer are never paid. The insurance companies fight back and forth about who is to blame and who should pay. So, when a patient calls to make an appointment to evaluate after an accident, we tell them they have to pay the office visit up front, at the time of the visit and then give the bill to the insurance company. Consequently, I do not see a lot of these types of patients

We would have cut him off last year as soon as he was 30 days overdue on account balance of $240. Or $50 for that matter.

What is the reason for today's visit. If it is an emergency, you are indeed stuck.

I think you do need to investigate what the state rules for dropping a patient.

I would agree that all future visits should require up front payment with the patient seeking reimbursement which then puts the onus on the patient to make the visit. You did not abandon him, he chose not to come because of the financial outlay.

Chris,

I need to say this politely.

The reason that he insists on coming to see you instead of someone else is that he feels he can get away with it. He has so far. You need to cut him off. And if he describes something that sounds like its an emergency, maybe you can say "My Goodness! Go to the nearest Emergency Department. No, I can't treat that! Go to the ER, and follow up with the hospital's primary care clinic!"

Thanks for all the helpful replies. I have not seen the guy in a year, and he did recover from his injuries and frankly I did not think he would be back. I talked to my attorney and was told that there is no outright standard for discharging the patient - many say 15 days but the insurance company legal department would prefer 30 days for their protection. I talked to another doc in town and they tell these patients they are overdue and will not be seen until their bill is paid. Don't do this! The attorney says that can set you up for abandonment claims - you either keep seeing them or discharge them. The worst part, is that this is a third party payer (the other driver's insurance had no medical), as his car insurance picking up the tab. This means they pay him a settlement and it is up to HIM whether he gives any of that to me! The patient tells me the offered him (us) a settlement but he refused it as it was not enough!

I think it is true, if we insisted on payment first we would have less MVA cases, and this might not be a bad thing. I love this board: you are so helpful - far beyond the AC issues!

You have No obligation to see a patient that clearly owes you legitamate funds for previous care. OK you have to make sure there is no serious life or limb pathology that will occur within the next 12-24 hours ( not a law, just simple ethics ).
If you see this patient and incur further financial loss, you have no one to blame but yourself.
Can anyone show me a successful legal proceding that was brought against a healthcare provider for not seeing a patient bc lack of payment? I doubt it.
Maybe your landlord, the phone company, the power company, your staff, and your mal-practice carrier will give you a discount b/c some of your patients owe you money. Sure they will.
Come on people!

Nate

What a minute... 5 previous unpaid visits?! This sounds like abuse!
How is it that a patient can be seen that many times without any payment? We document the patient's promise of payment,by the date of their choice.. we offer them to post date checks, but we will not see a patient if there is no honest effort to pay.
Any arguments? Ask them when the last time they pulled up to a drive through, gotten a meal without payment? Show them the payment agreement that they signed in your office when they first filled out new patient paperwork.. explain to them ITS A LEGAL AND BINDING CONTRACT.

If you are in a bind, then perhaps you have no accomodations within a certain time frame, and they can go to their local urgent care facility for this accident, then you will be in a position to send that letter, or make it clear there is no free fast food given at the joint.

Well, now that you mention it, it is abuse. Especially if he never intended to pay! He just said his settlement was coming through. I haven't had much problem with my MVA payments, but if this continues it will be cash up front!

In these situations, we tell the patient that they have to pay at the time of visit. Their health insurance will not cover it, so the visit is self pay. They can then file for re-imbursement with the auto insurance company. Same for workman's comp.

boondoc since you last saw him a year ago and he was cleared of injuries you don't have to accept him as an appointment till his balance is paid off.

Yes, I have a man who owed me 400 bucks, didnt pay over 6 months, then promised to pay me 50 a month to make it up...problem was I saw him driving a brand new 50k SUV.....he missed one payment and I fired him. He spread my name all over town as being a terrible guy and due to HIPPA I cannot defend myself. Sad thing..these charges were all copays...the girls in front now collect all copays at the beginning of the visit or I dont see them.

You know, HIPAA is about their medical information only isn't it. Can't you state that, you cannot comment on his medical issues, but that the reason his is spreading these wild rumors is that he refused to pay his overdue bill amounting to several hundred dollars?

The best way to force patients to pay there bill is to charge a monthly interest rate higher then credit card eg 2% per month and a late fee for any unpaid balance. As soon as the patient see this charge they will either pay there bill on time or not to come to your office and find some one else. I apply this policy to all patients with or without insurance. It worked will for me in the last 9 months since I started to adopt this policy.

Mohamed,

By charging interest, you are required to follow certain specific rules and laws. It varies by state. It involves the extension of credit.

What may be a legally safer option is to charge a flat "Repeat Billing Fee." The fee would be the same regardless of the amount of the bill. At least in primary care, most bills are not really high, so if you have a flat re-billing fee of, say, $5, it will be higher than any interest rate anyone would likely come in contact with (unless they borrow from an investment bank or loan shark.) Since you are not charging interest, this would avoid laws concerning the charging of interest and extension of credit.

I charge a standard $5.00 late fee.

I used to have a billing service and I have asked them to do this years ago with no success. the answer was always it is illegal and they can not do that.
I started my own billing in january of 2011. I have been using this policy since July of 2011. I Belive that was the best thing I have ever done in my pratice. Here what you need to do:
1) have the patient sign a form stating that he understand he will be charged a an interst(1.5%-2%)per month rate on any unpaid balance. As well as a late fee of ($20-$25) if not paid within 14-21-days.
2) add a note indicating the same on your billing statment each month.
At this point will become 100% legal in any state I have discussed this with a lawyer.
Off course you can easly set up a flate late fee only.
My idea about the high interest rate and late fee is to force the patient to pay as soon as possible if using his credit card if he has to. If the fee is too small like leslie $5 dollar they will not thing about payment promptly.
Once the patient signs the form at the first office visit. He will pay attentin to your bill like his electric bill and phone bill.
Be carefull not to charge any fee or interest on claim not cleared by insurance yet. I mean sometimes the insurance take 2-3 months before paying there part or they will refered to patient responsibility . Only then it will become 100 % legal to charge them.
After I noticed a success . I decided to have every patient old or new to sign this form as updated financial policy every years and I will keep a copy in AC.
For patient who has no insurance they will stop coming to you bytheself without the legal hassel of discharging them.
I hope this will help
Try it . If you have more questions please let me know.

Nice idea Mohamed. Your fees are higher as a surgeon, so the uninsured may stop coming to see you. In primary care,we like the uninsured. The fees are small compared to yours. So they must pay in full at the time of their visit.

I think I'm going to draft a financial statement on this with a $25 late fee. Either that, or start keeping the credit cards on file.

Todd, we do the same. Collect copays upon check-in. If they claim "I forgot my wallet," my staff have been known to say "that's alright, run home and we'll still see you. But bring back the wallet with your copay."

Patients never complain about paying up front b/c that's been the policy for years. We've had a couple of grumblings like "what if I don't like his service?" and my staff reply with a smile "you have to pay whether you have service you like or not, so pay up Mr. Smith."

Wayne
The problem with the uninsured for the surgeon is they never come back after surgey is done. Because of the associated high liability for the service we render I don't like to operate on patient unless I got paid. We offer upfront payment with discount if they agree.
The other problem that we see now is that most patient have very high deductable with $2500-$5000. Most of these patients do not come back after there surgery and they refuse to pay there deductable, simply because they have no need for my service any more. I have a patient who had a gall bladder surgery in 2004 she had a balance of $474 she refused to pay until I started to charge late fee and interest . She finally paid last week.
I undrestand that in primary care is good to keep those uninsured patient but my suggestion is to help collect there obligation quickly and to teach the patient there is no free service.
I goty my idea from all the people who provide my personal service whether he is the gentelman who is mowing my yard to my electric company and water company and my CPA . I had recently operated on a lawyer in town for acute appendicitis. When he came to my office he had to sign the form . He had no objection . In fact he agreed that once the patient sign the form they can not object on either the fee or the interst rate. His office actually charge 1.5% /month for any unpaid balance.
One last thing I would also add to the form is to add a clause that they be also resposible for all cost of lawyer, collection and court in addition to late fee and interest.

My advise is to have the patient sign this form as a seperat form and to be clear not in small letter. I can email you a copy of mine if you would like.

Mohamed,

I think many of us would like to see your form. Anyway you can copy it to a post?

Leslie
I will do that tomorrow when I go to the office

I could use a copy of that form also.

We try to collect before the patient is seen. I discount down to Medicare rate for all my self pay patients. I feel that is fare.

Unfortunately, the front desk does not always collect prior to the visit.

If I have told them not to collect co-pay for that visit, the patient feels that they should never pay a co-pay again.

As I said, your fees are higher. I understand your position. We have patients that pull those same antics with much smaller amounts involved, so I have no doubt you have to fight that battle and they are much quicker to try and "stiff" you. They figure they can avoid ever seeing you again in their lives, so they decide they should get out of paying you since they are ok now. I know the mindset.

Nice extra idea about the lawyer fees and collection fees.

Here is sample of the form
NAME AND ADRESS OF THE PRACTICE

PATIENT FINANCIAL POLICY
SIGNATURE SHEET




I, _________________________ HAVE RECEIVED, READ AND

UNDERSTAND THE FINANCIAL POLICY AND PRIVACY STATEMENT OF ?Dr. Or Practice name?.

I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR ANY BALANCE AFTER INSURANCE HAS PAID FOR A PARTICULAR PROCEDURE OR VISIT. I UNDERSTAND I WILL BE CHARGED A 2% FINANCE CHARGE PER MONTH IN ADDITION TO $50 LATE FEE PER MONTH FOR ANY UNPAID BALANCES.

If any amount owned becomes past due, in addition to such amount, I/we agree to pay all costs incurred by ?Practice Name ?pertaining to collection efforts including, but not limited to (1) court costs, (2) attorney fees, and (3) collection fees whether or not litigated. I further understand that if I default on my payments, all relevant information may be disclosed to credit bureau organizations.



X______________________________________DATE_____________

Thanks, Mohamed

you welcome

This exactly what I do for auto accident visits - they pay the visit and submit the bill to the insurance company