Home Forums Discussions General Discussion 120 days

Hi everyone,

I have always found the board to be one of the best places for advice on the business side of the practice. This topic came up today and started quite a stir.

We have always had good billers in our office, but it seems none were really concerned a lot about the 30, 60, 90, 120 days past due piece. So, since our newest biller is on top of this, we/I am faced with exactly what to do with them.

Some of the ideas have been:

Clearing the back balance (only for very small amounts, say under $50 to get them off the books.

Offering to allow them the option to pay 1/2 of the amount (especially large amounts like $600 and clearing the rest).

Setting up a payment plan.

Dismiss the patient from the practice.

Send to collections, then after one month; dismiss the patient from the practice
(What do youi do if they make two $40 payments for two months in good faith but then they stop paying again? Dismiss?)

Any of the options that lead to dismissal, always brings up the following issue. What if it is a patient that you would simply not want to lose. In fact, you just could not bring yourself to dismiss that patient. The patient with Dermatomyositis or Mitochondrial disease that you have followed for 14 years. Or just the family that you love. Sure, fair is fair, but it simply is going to come up. I suppose since, by definition, I am that close to them, I could call them.

What came up today which caused a huge stir, especially since my biller did not come to me with it first was what do you do with a patient who has been sent to collections and then wants an appointment? Do you turn them away by phone? Do you turn them away if they are in your office? Is it legal? What happens if they are self-pay, can't afford the ER or Walk-in Care and just happened to have meningococcemia? I should say that my biller thought it would be OK to see them if they paid on their bill. How much? 10%? 20%? My thought was if they are going to be dismissed after one month of collections any way, why not see them? At least you stay in some good stead.

Then, there are always issues which are just difficult to deal with. Say, somehow, a patient runs up a $800 bill. If you offer meeting them halfway, they are happy and pay the $400, you clear off the back balance, and you get the $400 you likely wouldn't have received. On the other hand, is that fair to the other self-pay patient who is paying his or her entire bill each time.

I think it is hard because from the moment one starts medical school, you start to develop this empathy that grows and grows until it is hard not to see everything from the patient's view, even when it means losing money or being taken advantage of. To use the now famous analogy, you couldn't buy a gallon of milk for half price. And, if you took your car to the mechanic, and somehow left with a $100 bill, you are not getting any more work done until you pay that off. Is it the intangible of health?

I would really appreciate any feedback on this subject. And, if anyone has form letters they use, if you wouldn't mind sharing them by sending to badams AT riverviewpediatrics.org_removespam. Thanks.

Ah, Bert, tough issue. I've been an FP for 35 years, 26 in the same town, in solo practice (a.k.a. "a dying breed") and have always struggled with this as well. As always, you have eloquently described the dilemma.

What to do about patients I've known for decades who have those 120 day bills? I have my staff put all the overdue bills on my desk to review. I look through them and we talk it over but how can I discharge a patient over a bill? Every once in a while they will talk me into it, if the patient has been very irresponsible and it seems that to let them get away with not paying the bill will encourage more irresponsible behavior. My collections aren't that great as a result. I suppose if Carl Icahn were my boss, he would fire me in a heartbeat, but I sleep well at night.

I guess I am out of touch, but still think this is a vocation not a job. I know there are other perfectly valid opinions and approaches to this issue, but thought I'd give you my feedback before I trundle off to bed.

I actually like that John. And, thanks for the reply.

You have to have a clear policy and you have to apply it equally to everybody. You can not go through a pile of bills and decide who you are going to give a break. It is wrong on many levels and it is just unsafe for you. You are setting yourself up for a discrimination charge and complaints at very least. Very difficult to defend.
Nobody should run $600 bill, they should be dealt with much earlier. I have seen all your ideas at work with partial success. The most important thing again is that your policies have to be clear to the patient and you have to be consistent in applying them.

Bert - I have the same issue - I have the same issue. I have practiced in the same small town for 13 years and have many patients who have run up hundreds of dollars in charges and virtually never pay any of the amounts their insurances do not pay. Unfortunately we as physicians are poor at telling people who do not pay to go away.....if you find a solution let me know and until then I will do what most of us do is continue seeing them and being a bit annoyed that they don't pay. It is why we solo physicians are a bit of a dying breed. I guess it would be better if I got a paycheck and I never knew how money got collected.

I am solo too. I don't see patients who don't pay. Why would I? If they don't value my services they better leave. I have payment plans, I don't send pts to collections because it is useless with primary care charges - no collection agency would vigorously go after them anyway. Plus I have had quite a few patients to come after two-three years and pay in full. They can not be seen unless they pay. No ifs, ands, or buts.

Nearly every solo or small group practice has faced, faces, will continue to face the same problem in all of it's variations. In our 40 years of practice, we think that we've seen it all, only to discover that another insurance configuration creates another, similar problem.
We, gently, remind our patients that, in essence they are asking us to commit fraud if we discount our fees by not collecting that which is contracted for services. We tell them that this money has ALREADY been applied to their deductible, and that our taking less from them is a felony subject to fines and jail for all parties.
We remind them that HIPPA allows them to opt to pay us in full for services going forward, and that we not report this to their insurance, but, that in doing so, they cannot have this payment reduce their deductible.
This, sadly, doesn't always work, but serves to alert patients, at least in part to the practices side of the problem, so that the don't see us as being greedy and after their money.
When patients have to assume the cost of care at the time of their visit, their eyes (and wallets) are opened to reality. We have always felt that the whole insurance house of cards would cave in. This may be the start.

Thanks, again, everyone. Great input. As the weekend goes on, I will think about this. It is difficult, because I have my biller and my practice consultant all throwing in ideas, laws, etc.

Mnemonic does make a lot of sense. And, I do feel that patients should pay for my services. It's just what is the best way to do it.

Yes, you have to be consistent. But your patient mix, like most things, is a bell-shaped curve. On the right tail are the patients you hope never pay you, so you can show them the door. But, there are always going to be patients you enjoy working with much more so than the ones under the middle of the curve. I have ten patients I could name off the top of my head that I would absolutely hate to lose. I would practically pay their bill for them.

I have often wondered (although I am sure there would be a great downside) what would happen if I actually brought it up in the room. As a parallel, there are times that my MA will tell me that the next patient is rather upset about the wait or fill in the blank. I go in, and they are sweet as pie. While I would likely be uncomfortable confronting patients about their bill, there is a bond there that is unmatched with others on your staff.

Here is some food for thought. I have 65% MaineCare. Hard to believe but none of them have a back bill. But, I suppose a single payor system would solve all this while it would cause many other problems.

Bert, there have been some good suggestions. Some I will parrot. You do need to have a consistent policy that you apply to everybody. Now, everybody already freaking KNOWS that they are to pay you, but they just feel they can "get away without paying you." You also need to have billed a patient 3 times with 30 days between billings before sending them to collections. For larger balances, collections will work. I've done it.

I suggest reviewing your records on each one to see how many times they have been billed. Then resume the 3 billing notices system which is rather standard. If someone has already been billed 3 times, send them a nice letter stating that if they do not pay their bill within 30 days they will be sent to collections. If they have a larger balance ($200 or more), offer to arrange a payment plan of $50 per month to be automatically billed to their credit card. Anyone who balks at this should be dismissed.

Announce a new policy that all patients (or their gaurdians) must leave a credit/debit card on file pre-authorizing you to charge future outstanding balances to it. Put a cap on a single charge ($135 is a good one). Higher amounts can be given a payment plan that will automatically charge to their credit/debit card. Have a document outlining how this works and have them sign it. It should contain the last four digits of the card and the expiration date.

Updox has a facility whereby you can store credit card numbers and charge the card. Credit card numbers are stored by a company specializing in this named Braintree. This was the single best thing I did to stop our growth in accounts receivable. It was like it hit a brick wall. Yes, Alice is uncomfortable confronting patients about their bill, but she is getting better at it. But primarily I do it.With her its only when they think they can "go over my head." They don't realize that i'm really her business partner, and we separate duties to basically she's in charge of medical issues (I can't do that) and I do ..well..everything else.

I agree with you about the bell curve of patients. No, you should not bring this up in the room. In fact, you should separate yourself from it as much as possible. We too have patients we would hate to lose, and some we lost. Others left and came back. After awhile you end up with patients who actually respect you and your service, not just pretend that they do.

When you use Braintree, do you set up a card for only those with a back balance or every patient?

It is standard in my area that payment is due at time of service. We check with the insurance company the day before or on the day of the appointment, see what the patient's responsibility is that day, and the patient pays prior to being seen. We almost never have to send any bills to office patients (only in unusual circumstances). No one runs up a bill. Patient's know ahead of time what is expected, and they do not assume a debt to us that they cannot afford. Payment plans are used occasionally when needed, but they must be adhered to in order to continue to be seen. Payment plans, like payments, should be worked out before the patient is seen. Having a standard policy in writing would be helpful for that, and the amounts and payment dates could be written in blanks. For hospital patients we try to get the bill to the patient as quick as possible and we do provide discounts for prompt payment.

Thanks. I hope this can be an open dialoge. I don't want to ask for help and then feel like I am arguing. I am guessing you are a subspecialist in neurology where you see mainly referrals? Or a different type of patient.

I guess I need to have everyone tell me to be tougher. I just find it toughest in pediatrics to have a child with strep throat come in and then have to turn them away because they don't have the money. I completely understand the fact that they are not paying me for my time. (Although we would bill them). We, too, check the day before.

If we told that family we couldn't see them, I doubt we would see them again. Now, I would agree with anyone who told me that this is the family you don't want. I guess I am not disagreeing as I am more looking for what is the best thing to do in that situation.

No, Bert, you don't have to be tougher. :-)

Indeed, how can we turn away a child who is sick, any person who is suffering? My mentor never turned away a patient. He never went to med school, had no fancy diplomas on the walls, yet he gave sight to the blind, enabled a paraplegic to walk again, healed all who came to him. He was born 2,000 years ago but is still revered as the Great Physician.

Yet, in caring for patients and not asking for payment for our services, we sometimes can do harm as well. It can lead to a sense of dependency. I often tell patients, "Pay it forward." The uninsured patient may have no money but everyone has some gifts that they can share with others. I say, "Pay it forward, do something of equal value for someone else in your life this next month."

Every clinic, including mine, will do some degree of charitable work. Look at your numbers, decide what your clinic can absorb, and how much of that you want to do. This decision affects all of your clinic, such as employee salary and benefits, upgrades to equipment and so forth, not just your own salary. Once you have made the decision, stick with it and stop worrying about it. You can re-evaluate this every quarter or year, and if you want to increase charity work after these evaluations, then go ahead. You also decide under what circumstances you would provide unpaid services (severity of illness, financial hardship issues...). You can budget this on a monthly basis, to help keep track. Any patients you cannot accommodate can be provided printed information or info by phone about community/county resources. If there is a like-minded pediatrician or two in your area you might take a team approach on this to spread out the load. This policy should allow you to see a number of patients who cannot pay at the time of service, and as you have noted some will be able to pay later. The important thing is that patients (in your case, parents) understand explicitly up front what is expected.

For example, if you want to provide care to a patient that cannot pay their individual responsibility at time of service, give them a payment plan that is fair and reasonable, even 10 dollars a month, and if they stick to it great, but if not they need to know ahead of time that they will be discharged from the clinic, again with referral to community/county resources. Try to anticipate the cost of included necessary follow up visits in the payment plan. If you decide to provide free care in a case due to the circumstances, then agree to that up front.

Note that in your case truly impoverished families should qualify for MaineCare, so should not be a problem in this issue. It has been my experience that the lower middle class gets pinched the most in these situations, unable to qualify for aid, but cannot afford insurance or deductibles.

As a last resort, you can always reach into your own pocket (literally, not figuratively) and pay for a patient's visit. This way only your own income is affected when that happens, and you always have a safety net for your soul when that heart-melting case is brought in by their desperate parent at the end of the month and you have used up your budgeted charity allowance.

I have done that myself, telling my office manager, "I had to do that or I would have gone straight to Hell".

So, budget so you know what you might do, plan so you know how you will do, and then you may be surprised what you can do.

Bert, we set up a card for every patient. When the EOB comes in, we automatically charge them. Yes, we do send them both an invoice and a receipt. Its easier with V6.6 the newest one since you can print out invoices with notes on them. So the note says "$17.34 balance due, coinsurance, issues addressed during preventive." and then another entry for "payment received." Plus the credit card receipt. Previously, I had to turn on quickbooks to insure I had a proper receipt with explanations. (for me as well as for the patient).

Oh, by the way, Dr. Howland, your mentor switched to mostly telemedicine in his 30's. Pretty much have to die to get a face-to-face appointment with Him now.

There are all types of threads on this board. I have started a few where I asked for other's help on a subject I know little about. It is unbelievable the responses I get. John, if you would write my letter for connections that would be great.

Headcase, you have given great responses, and your spelling and grammar are impeccable. Always appreciated. I love the line about come up with a policy and forget about it. These are the things that being in a hospital group can be helpful. By the way, may I ask a favor? Can you put your first name in an auto-sig at the bottom, so I can refer to you by name? Up to you.

Wayne, just tremenous info. I was lucky to have AC when I started my practice so all my info was clean. But, how do I tell all my self-pay and insured patients that they now have to have a credit card on file? I would love that. Just asking. You know, most of our back balances are due to uncollected copays. Would love to have a CC just for those.

I know what I will get on this. But, I will throw it out there for suggestions. My receptionist is not good at getting copays. The only reason she is here is because I have never seen anyone better on the phone. She may be the best in Maine. Unbelievable. I know that asking for copays are difficult, but it is also her bonus, her raises, etc.

Would love to hear from Leslie.

Well, I have a couple of thoughts on this. For many many of the 25 years I practiced independently I was not aggressive about collecting. Insurance reimbursements were adequate for me to make a decent living and pay my employees above average wages and cover my overhead. I subsequently just wrote a lot off. However, with diminished reimbursements and higher deductibles which throw the payment burden back on the patient, my collections faltered and well.....simply put, put me out of business. Overhead went up, payroll taxes, blah, blah , blah...you all know what is going on out there. So, several years before throwing in the towel I started getting tougher. I realized that those same patients who failed to pay their deductibles would themselves never tolerate not getting paid for the work they did. And, more times than not, they were the same ones that just finished telling me about their terrific trip to Alaska or their season theater tickets. So, for those who were insured but who failed to pay their deductibles I asked them nicely twice by putting alert stickers on their statements to settle their accounts. I offered to set up what was a very generous payment plan allowing them 90 days to pay off their account or to put it on a credit card. If they ignored that, I sent them a letter saying they were in fact committing insurance fraud and that my next step would be to notify their insurance company of their failure to comply with their contract plan and that, if I did that, they would be dismissed from my practice. I never really notified their insurance company but it did incite many to settle their accounts. For those that didn't, they were dismissed. I spoke with each one one last time personally explaining how my employees expected to be paid, they have families to care for and that (near the end) explained to them that I had not had a raise in 12 years. Would they tolerate that in their job? If that failed, they were gone.

For the uninsured, I did cut deals. I asked them to pay me $10/month if that was all they could afford. As long as they tried and as long as they did not take me completely for granted all was well. Almost a year after closing my practice I am still receiving monthly payments of $10 from about 5 patients...God bless them.

In the end, I am not sure that having a more aggressive collection policy would have saved me but if I had to do it over again I would have been more clear early on and made sure my patients knew where my office stood. How many times did I hear from them and from friends and family about Dr. So and So who demanded payment up front before ever seeing them. It is unfortunate that we physicians can no longer actually provide charity care because we are having increasing difficulties just being able to provide any care, paid or otherwise.

Since closing my solo practice I have received numerous emails and calls....3 this week...from former patients saying how much they miss me and my office and how badly they wish I could have been able to sustain my practice. None of them were from delinquent patients.

So, with that in mind, I guess my final thought is that, you have to think long term...what does the future look like (sad, I know)...and what changes should I be making now in order to meet that future head on. Would it not be better to be a bit harder on the slackers in order to be able to continue to practice the kind of medicine the great majority of your non-slacking patients have come to appreciate. In my case, I came to that conclusion too late.

Thanks Leslie,

Once again, it is the 3rd party insurance industry which makes this difficult. As stated before, our back balances usually consist of uncollected copays.

I am not very good at the business side. I do have someone who is. My question is how, besides that the patient has a contract with the insurance company, is not paying a deductible, insurance fraud. Just asking. It would seem like that would be advantageous to the insurance company as their deductible would take longer to be met.

It is interesting that is basically a mindset. It isn't so much that the auto mechanic (not sure why we always use that guy), is tougher on customers, it is just that 1) for years that has been the expectation and 2) I don't think there is the same rapport. And, of course, it is cash only, and your car keys are held hostage. And, if you don't make your car payments, the car WILL be repossessed.

I charge insured and self pay patients for their records when they transfer for no obvious reason. Most freak out and threaten to call an attorney over $27.45. It is not that they disagree with the fact that it does take time for my receptionist to gather them, burn to a CD, put it in a CD mailer, write down the name of the practice and send it out. It is the fact that they have never been charged by any other office. I never have an issue with a first-time patient as they think it is the norm.

And, I think it is the norm that patients think doctors are 1) rich and 2) the last person they need to pay. We also don't have a corner on the market. Time-Warner, the other day, whom we had paid and had not sent us a bill in three months even though we called them and "begged" for one, just turned off our service in the middle of the day. No multiple invoices with stickers, no collections, just flip a switch. And, that will get a check in the mail rather quickly.

Then to add insult to injury, we get 10 faxes a month from electric companies secondary to a patient who simply can't go without electricity even though they haven't had an asthma exacerbation in three years and are 14 and could easily use an MDI. We now have them come in THAT day and give them an MDI sample and charge a visit. We do sign the fax as I am sure we would be liable if he went home and had a bad attack from their cigarettes. We write the same thing on all of these: asthma and nebulizer. Yes, we could say no, but the page at 10 pm kinda sucks. Just easier to fill it out in ten seconds and fax it back. I had to talk to Bangor Hydro the other day, and I told them, "Do you realize that 95% of these are completely bogus?" You can imagine their answer.

But, I digress.

As a bit of an aside...

The biggest issue for me for dumping Medicare was the threat of being charged with a felony for charging someone less that Medicare rates, and this was (in Anchorage, anyway) interpreted to mean not aggressively pursuing co-payments or payment from the uninsured. Getting out of Medicare allows me to charge whatever I feel is right, and no, I don't have a clear and consistent policy. Some folks can pay and don't want to (as per Leslie) and some would struggle terribly. I have no wish to allow my compassion or judgment to be ruled by an algorithm or policy. I hound, fire, or send to collections those who blow me off, based a lot on how much or little I like caring for them. I write off the rest.

The best solution for reducing patient accounts receivables is to prevent it in the first place. You won't be able to fix all the stuff that is currently in receivables but the situation will get better over time.

I echo Leslie and others thoughts about the way it used to be and how we could let a lot "slide."

No more. High deductibles and lowered reimbursements along with ever increasing expenses mean either collect it efficiently or go broke. There will also be a few exceptions where the receptionist asks me to "override".

Collect copays when the patient checks in.

Also, we have started preauthorizing $150 on a credit card (placing a hold, not charging) for every visit up front for patients who are expected to owe anything. When the EOB comes in the patient's responsibility is charged to the card and they get a receipt by email. If their responsibility exceeds $150 the patient also gets a statement by the US mail for the amount over $150. THis is all done automatically by our practice management program (not Amazing Charts). We have a 1 page handout explaining this process to patients that we handout up front.

Bert, we don't keep CCs on file for self paying patients. They know they are expected to pay in full when they come. If they can't, they know to discuss it with me and I will work out an arrangement with them. Our 2nd most reliable payer ever was a woman who was self pay. Uncontrolled DM2 when she came with non-healing foot ulcers. Her daughter insisted she come because she was not improving with the treatments she was getting from the neighborhood free clinics. She often didn't have the cash to pay since she also had to pay the podiatrist upstairs. But she always made payments and never complained about the fees . Her daughter finally got her onto medicare, but by then we actaully had he on insulin (she was afraid of it so that took some work) and her foot ulcers were long gone. My overall favorite patient ever.

But to get back on topic, self pay patients don't need to leave a CC on file unless they really want to. Insured patients do. We did lose some, but not too many. Some I just had to talk to a little to explain what Other people do, and that a policy like this can't be used on individual patients--it must be everyone since we don't discriminate. I also liken it to having Netflix, or staying in a hotel or renting a car. They automatically charge your card if something from the room is missing, or if they find damage to the car. The vast majority (at least in NYC)just do it.

Here is where you need to take off your rose-colored glasses. It is obviously a one-sided love affair if your patient does not care or respect you enough to value the 14 years of marvelous care you have given their child and to pay you for those services.

Bert, you sure know how to get the juices flowing for a good thread!

True. Just a formula of four things. Asking for help and showing your humility (which is a definite here), a good topic, great fellow users, and no hijacking, lol.

Many doctors are poor business people because they agree to work for nothing. How many of you would tolerate people eating a dinner at your restaurant, and then purposely leaving without paying? My staff will not work for free, and neither will I. If you want to give charity, just do it. But failing to collect on your past due accounts is not fair to your other patients. I have plenty that lack funds but pay their bills. Why shouldn't they get a discount? Should you just give a discount to those overdue by writing it off?

If patients call me, I'm glad to set them up with a payment plan. I even allow small amounts, but they have to keep up with the services they are using. I give a discount to self-pay patients. Sometimes when people get into a debt they cannot pay, I will write off a large portion if they will cover some of it. Other people do not pay, and never had any intention of paying. We see more of this as deductibles have gone 'through the roof' under Obamacare. You have to feel for the patients, who are bearing a higher cost of healthcare under the "Affordable" Care Act. However, you also have to respect yourself.

My plumber makes 200 per hour and charges 100 per hour for his apprentices on the site. He does not give me a break, offers no cash pay discounts, and does not work with insurances. He's busy beyond belief, and people pay their bills. Patient also pay $150 per month for the ever present smart phones, pay more than $100 per month for cable television, pay $200 per month extra in fuel to drive monster trucks around, and pay $300 -$600 per month in cigarettes. So why should you be the last to get paid? Because you are easiest not to pay.

Legally, you cannot refuse to see a patient because of their bill. This would be abandonment according to my counsel. Your only choice is to discharge them or eat the balance.

It has been since the end of June that this thread stopped. I received some great information, which helped me with a lot of decisions. But, then as we moved forward, more problems popped up. So, just wondering what others do.

So, we send out a bill at 90 days letting them know that if it is not paid or a payment plan is not setup, we will be forced to send them to collections. At 120 days, we send a letter letting them know we have sent them to collections, and we will have to discharge the patient. We will continue to provide services for 30 days.

So, the 30 days comes and goes and now we have five or six "new" patients to add to the "no longer our patient list."

So, now after four months, we have maybe 20 patients minus eight who have settled in some fashion; so 12 who are either in the one month "grace" period or have been discharged.

These patients call in for something: an appt, a script, something. Our staff has to look at the list on their desks and determine if they are in collections but still our patient or not our patient. Then, they have to tell them they are no longer out patient if they aren't. Or, they just overlook it. Now we have a patient in the office who is not out patient. So, I guess I explain to them that they are no longer our patient, but I will see them this time?

I had a patient page me the other night about strep throat. And, she wanted a referral to an ENT. I knew the history and decided to go ahead and make the referral. The next day I saw the list and realized I had just referred a patient who is not our patient. Can I make that referral? Should I have made that referral?

I am used to patients no longer being our patient. But, it is more clear cut. If they send for records to trasnfer, they generally don't call us again. And, if we remember, which we would usually do, we don't see them. It isn't anxiety provoking to say, "But, you transferred two months ago." Or, I have an issue with a patient, and I dismiss them with a letter. Usually, with that type of thing I send it return receipt requested. This doesn't happen often. Maybe two to three times a year, if that. They don't tend to come back either. And, given there was an actual reason, it is easier to be up front with them. And, worse case scenario, you can print the letter out and give it to them then. While physicians will consider referring to the ED or not doing physicals during the 20, 30, 45 day period you give them, I just see them. Because they usually don't come in.

The analogy to the plumber, while completely understandable, isn't a great analogy. They don't continue to service the same client as often. They don't get paid but have to wait on the insurance or bill for a copay. They don't find themselves with a good customer who for certain reasons owe him or her $95.00. For them it is, "I fixed your sink, I need $125.00. If you don't pay it, I am not sure what they do to try to collect, but I am sure they don't work for you again, at least unless you pay the bill.

Now, you have a patient, you sent to collections. They are 15 days into the 30 day grace period. The collections thing works, and they want to set up a payment plan. They pay this for three months on time. Then, they come in and can't afford the copay. Or don't pay due to deductible. Do you dismiss them? Do you not see them right then? Do you start over? I am not arguing, it just isn't clear cut. I am wondering what others do. Especially, if they miss a payment. And, I know there are the credit card things where they automatically pay us.

Or do some dismiss them at 90 days and send to collections at 120 days? There is also a huge difference between a patient with Aetna who runs up a bill due to a large deductible and never plans on paying it. Or one with self-pay who runs up a $250 bill, but intends to just keep coming in. Those should be dismissed and sent to collections.

But, we had a MaineCare patient the other day who was $300 in debt. Generally, MaineCare will kick in and pay anything within three months. Generally, if you are MaineCare, you can go to any doctor with the understanding that you will never have to pay anything. But, something screwed up, and it went five months. My biller tried to send her to collections and dismiss her. I stopped her. For two reasons. One was because it really wasn't her fault that this happened. A 19 yo single mother is supposed to just know she needs to check and see if she has a balance. Is she supposed to call MaineCare. I don't call BC/BS every month. But, the real reason is simply business. Even if she owed me $3,000 and told me she couldn't pay $1.00 a month, I know that for the next 18 years, MaineCare will pay me.

So, anyway, maybe I didn't articulate it well, but that goes to the whole issue of why I am confused about all this. I guess part of it is, did they get the letter? Do I send it return receipt requested and fall $2.40 more in the hole? Or do I take the fact that it didn't come back that they got it.

I guess the best thing to do it, send them to collections and dismiss them in 30 days which is all sent in a letter. Then after 30 days, they aren't our patient anymore, and you just have to have that pop up when you bring their name up in the scheduler.

Just wondering if anyone else has issues like these or what their policy is.

Bert, from a legal standpoint it is very important to stick with your policy and not play games in the realm of 'patient abandonment.' They should all go to collections after 3 unpaid statements if they will not set up a payment plan or make any attempt to address the bill. Doctors just aren't good business people in many cases. Think how a lawyer, plumber, mechanic, cell phone company or anyone else would do it. Despite your good intention, you aren't helping them in life by teaching them to be irresponsible and rack up bills they cannot pay.

Once they go to collection, you are turning the bill over to someone else and you will not be paid the full amount. At this point, you need to discharge them or you will get into a big mess as they continue to present without paying. They are also more likely to sue you after you send them to collections if you keep seeing them. Tell them it is the office policy to send them to a different doctor after they have gone to collections, as they have made no attempt to settle their bill over 90-120 days of reminders. Make sure your letter tells them how to find a new doctor, what urgent care offices and ER facilities are open, and to call the local hospital for referral ideas or their insurance company. Tell them they have serious medical problems they need to follow ASAP with their new doctor, and that records will be promptly released on a signed ROI receipt. Give them 30 days and do NOT see them again. If you see them again, you 're-establish' them legally as a patient, and you are responsible for them from then on. There must be no gray area here concerning whether they are your patient or not. After the CERTIFIED discharge letter, I set a reminder in AC for 30 days to INACTIVATE them. No need to keep a list: they are not your patient at that point. If they call, the staff asks, "did you get the doctor's discharge letter?" Well, we have a signed certified copy. Please read this again and take appropriate actions.

You Said:
"I had a patient page me the other night about strep throat. And, she wanted a referral to an ENT. I knew the history and decided to go ahead and make the referral. The next day I saw the list and realized I had just referred a patient who is not our patient. Can I make that referral? Should I have made that referral?"

You have now established a doctor-patient relationship again with the above patient. You have to do another discharge letter of 15-30 days and not establish with them again. You are accountable on following up on that referral, liable if they do not go, etc.

When people say they are transfering, and ask for records, instead of a discharge letter I make them sign a form that says they are withdrawing care on this date and have received a free, full copy of their medical records. Any future requests will come with the usual record research and copy charges. Put that signed patient withdrawal form into their chart!

In your plumber analogy, you have to pay the bill or collections, small claims court perhaps. They do not ever work for you again. Although he is a kind person, he will tell you to go elsewhere and will not fix your sink, even if it is flooding your house. That is your problem and your burned your own bridge. Why should people abuse doctors any more than plumbers?
You said:
"Now, you have a patient, you sent to collections. They are 15 days into the 30 day grace period. The collections thing works, and they want to set up a payment plan. They pay this for three months on time. Then, they come in and can't afford the copay. Or don't pay due to deductible. Do you dismiss them? Do you not see them right then? Do you start over? I am not arguing, it just isn't clear cut"

You discharge them when they go to collections. They had a chance for a payment plan, as offered, BEFORE they went to collections.


This being said, I am not a lawyer and it is only my 2 cents, and the above should not be construed as legal advice. I give people every chance, and if they a reasonable person with a large balance, I will often offer to settle up for half if they are in trouble. But they must make some attempt at being an honest person. I also give free charity care. But it is always my decision to give free care, and as such, it is a free gift of my time and expertise. It is not taken by force from an abusing person, because that is not a gift at all.

Boondoc, this is pretty much the system I set up here and it is good, accurate advise. The only thing I would add is that your 3 billing attempts must be at least 30 days apart. So I set up a reminder to check and see if they have paid the bill/rebill patient so that I am sure to get the 3 billing letters out.

Hi Boondoc,

Thanks for the info again. I hope this doesn't come across as arguing with someone who is giving me advice, it just brings up questions. The very questions that have come up with this process.

But, you don't discharge them until you send them to collections. It is at this point that you would send them a letter explaining about how to find another doctor, ER, etc. And, that they have 30 days. The whole idea about the 30 days, less if you wish, more if they have multiple or severe medical problems which may need to be addressed longer, is that you are still responsible for their care. That is more than referring them to a local ER. If they request an appointment or walk in, and they are sick, you must see them or it is abandonment. Again, why give a 30-day notice if you aren't going to see them at all. And, I would argue if they walk in or page you, you would be better off taking care of them, lest they say you refused to see them due to their back balance. After the 30 days, they are officially not my patient, and I do not need to see them. But, as you state, they are more likely to sue you during that period, but you have to see them during that period.

So, you can send them to a different doctor, but they have 30 days to find one.

It is my understanding that if the patient has complex issues, it is important to give them more than 30 days. Thirty days is a number that people generally use.

I agree I am liable on following up on the referral. But, I don't see where I am liable if they don't go. I have plenty of patients in my practice in good standing who don't go to referrals, and other than reminding them, I am not liable for their decision.

So, again, you may have to see them again, unless I am missing something. Again, not trying to completely disagree. It just isn't so straightforward.

I agree that it is a good idea to send the collections letter and discharge letter as Certified Mail, Return Receipt Requested. But, what if you do not get the return receipt. I guess you could hand deliver it to them the next time they come in and get a signature. I generally don't put my return address on the Certified Mail, as they likely know what it would entail.

On the 30 window after the patient receives the discharge letter where one is still responsible for the medical care:

In my experience it is rare that patients actually ask for care during this period.

See, this is why I asked this question. In my experience, in the four months since we have become a lot more serious about collections, it has been quite frequent. First, I think it is important we look at the three types of discharge.

First, there is the patient who voluntarily leaves the practice due to relocation, insurance changes, not satisfied with care, etc. In those situations, I have not had a patient come back for a visit in 18 years. Now, some have asked to come back and most of these (unless they relocated) are allowed back.

Second, I send a letter of dismissal to a patient because I no longer wish to have him or her in the practice. They have done something like shout at one of my employees or no show multiple times. I give them 30 days from the date of the letter. Again, problematic, because I don't know when they receive it unless I receive a return receipt. None of these have returned, because it is human nature to not want to go to a doctor who has just told you he or she has kicked you out of his or her practice.

Now, the third one. This is the one that applies here. If they receive the collections letter and the dismissal letter, there is a fairly good chance they won't return. But, there seems to be a ten day period or more where they don't seem to have received the letter. Or they just don't care. Or they are brought in by a different parent (happens a lot) in a split family. They call to make an appointment and come in like nothing has happened. And, in these situations, it is hard for the staff to say you can't come in, because it is within the 30 days.

Bert: I have discussed this with a lawyer at my malpractice insurance company. There is no set rule, and you can give 15 days, but my company recommends 30 days. They have 30 days, period. They may come in for care during this time, but rarely have I seen this. Your scenarios:
1. I try to send a goodbye letter when people are leaving. It is like a discharge letter, but says it has come to my attention that they are leaving town, etc etc, and I feel it is important to start with a new doctor right away so all problems are addressed. I also tell them I will be 'closing their chart' in 30 days, but will send copies to new doc, sad to see them go, etc.
If they come back, they are not a new patient again until approved. They are generally new anyway after 3 years inactive.

2. You do not have to continue seeing them, as far as I undestand, if they have been hostile. Threatening is a whole new realm, and you cannot be asked to subject the staff to abuse. I have immediately discharged someone, asked they never return, and told them they are 'trespassed' from the property, and informed police. In such a case, they are arrested if they come back. They are told the ER is open 24 hours and it is really hard to claim abandonment when there is an ER and Urgent care down the block.

3. They CAN come in for this case. Make sure your staff knows they absolutely CAN come in over the next 30 days. I have seen offices where the nurse says "you can't come in until you pay the bill." That is WRONG and could lead to a lawsuit. They have a right to the care over 30 days as long as they have not been abusive. And yes, you may be treating them for free - but this has rarely ever happened. If you have a chance to talk with them and hand the letter, it saves postage. Document it was hand delivered to them or have them sign that they got it. When they pick up records, as I said, I have them sign receipt.

I found out this stuff because my previous partner gave me a bunch of vicious patients. I spoke with the lawyer at my insurance company. You can to, and I'd suggest it. They are glad to talk with you free so they can save themselves money!

I will read this later. Too much right now, lol. Thanks for your help.

Thanks.

1. I don't send a letter once I receive a release. The moment I receive a release of records, according to my attorneys, it is a declaration by the patient that they no longer need my services, and since it shows where they want the records to go, that doctor is responsible. I would consider a letter saying goodbye if they left on good terms, but not if they didn't. That's just I.

2. I like number two.

3. I like number three as well.

I think basically it boils down to they either are abusive as you say or they have been fully dismissed.

Thanks! We have a meeting today at lunch. Glad to get your input.

Well Bert, How did your meeting go?

Thanks for asking. It went very well. We started to put a plan in place. Actually, practically got there. So, the plan was to send the collection letters and dismissals via Certified Mail, Return Receipt Requested. If these did not come back, we would send to collections and give the 30 day notice of dismissal the next time they came in by hand delivering them and, hopefully, obtaining a signature.

Well, today was the first example. It got all screwed up. First, the biller was under the impression that by giving the letter, the patient would have ten days left, because the letter was sent out 20 days ago. I am not comfortable with that. Second, the fact that this patient had an appointment should have been noted well in advance, and the receptionist should have been aware at 8 am and not ten minutes before the patient arrived. So, the patient is triaged, and I am seeing the patient. I have no idea what any of my patients have in a back balance or anything else about their situation. It's a great and fun family (doesn't mean I won't dismiss them), but I am in the middle of a great well child visit. Then a message appears on my screen stating. "Can you come get the letter of dismissal and give it to the mom?" My reply? "No, I can't do that." Apparently, we need to have a better algorithm.

A lot of the problem is that the staff (and I know it is my decision) are in odds of the new policy. They are not used to this after eight years. None of my staff wants to kick anyone out even though I am starting to see the light. But, it is worse, because my biller who initiated all this loves NOTHING in her life more than to send a patient to collections and dismiss a patient. She does fairly well with working with the patients before it gets to this point (fairly, not very good). So, sending the patient to her to go over this is definitely the best way to get rid of the patient, because I doubt they would ever come back the way she would likely handle it.

I don't know. It's a tough situation. I know giving it to them personally is the most sure fire way of knowing they got it. But, I just have a hard time, saying "Here is a letter of dismissal. Please have a seat, and my MA will be right with you."

We're trying.

Hi Bert,

I didn't read all the replies, but I have a tip about dismissed patients getting appointments. We don't dismiss patients for owing, but we do dismiss fairly often for multiple no shows. We mail 1 certified letter and 1 regular mail letter to the parent. At that point, I inactivate the patient right away and put a note that they are dismissed in the yellow note in demographics. The letter does say we will see the patient for "emergency" visits for 30 days. If they call within 30 days, staff will not find patient in the active patient list. If not found, they know to search under "all patients," so if they are found, the note about being dismissed is very clear, and the appointment won't be made unless it's a sick visit. (And staff will also tell them they have been dismissed.)

Thanks serene. Good information. Can you tell me what your protocol is for patients who have back balances. I am struggling with that one. Especially, since once they are sent to collections, it is difficult to accept any money on their back balance.

Bert,

I do the posting, so if I see anything is owed by the patient, I mail a statement and write it in the yellow note in demographics. (I also will write it in the siblings' charts.) When they come for the next visit, they have to pay the back balance, but we do allow a partial payment. I took a collections class, and they told us to say "how much can you pay" - having them come up with the number themselves. And not say "do you want to pay your balance today?" The answer might be no and that will be the end of the conversation. Usually we just say "you have a balance of $___" and pause. Usually the parent will offer to pay or ask to pay a partial amount. For partial amounts, we will say "when will you pay the rest?" and write it down on the superbill. This way the patient understands that we're serious about collecting the rest of the balance. All this happens before they see the doctor. Our check-in person is very good.

Now most patients who owe do not have a large balance. We check all benefits pretty well and collect deductibles and coinsurance pretty close to the right amount. (This took while at the beginning to get all the contracted fee schedules.) There are some patients that owe that have not come back to see us, but not a large amount. We have not sent them to collections, but if they ever show up again, they will have to pay.

Once every few months I generate a report of balances and resend statements. That's really all we do. But most patients seem to come back here so they end up paying it off. The people who don't come back, I guess we will have to write it off at some point in the future. I think the balance is not big enough to make a collections agency worthwhile.

We do have some people who call to pay when they receive the statement in the mail, but not a lot.

Oh and after we got V6.3.3 (which we're still on - I'm afraid to upgrade!), the ability to link the charts to siblings has been really helpful to collect when mom/dad comes in for another kid.