Home Forums Discussions General Discussion Large unpaid balances

I have between three patients in a nuclear/unnuclear family around $2000.00. The issue that I have not run across that often is the following:

Patient 1 owes a small amount of money
Patient 2 owes a significant amount of money

The mother owes a significant amount of money on both her sons above.

Patient 1 is the father of a three-year-old and still has parental rights although he never brings her to the doctor. She owes around $300, but is now on MaineCare so we do get reimbursed for her.

The grandmother (mother above) brings her in for all her visits.

She has been continually billed and warned about dismissal and collections for the balance on her two sons and on the balance of the grandchild. (I am not sure she is legally bound to pay for her -- but I can tell you her father is not).

It is quite obvious that we should turn over her two sons' accounts to collections. She has received the prerequisite letters and phone calls.

Do we continue to bill the biological father for the granddaughter? If he does not pay do we dismiss her as well.

What do people do if they have two children in their practice and one has to be dismissed, but the other one has no balance. Do you keep them in your practice or dismiss the entire family?

We dismiss all siblings in this scenario, but not necessarily the 3yr old. If you dismiss dad, he/grandmother may also choose to take the 3yr old elsewhere as well. I would probably send the granddaughter's account to collection at that point as well. If you're ok with the fact that you are receiving reimbursement for her now through MaineCare, and would be ok dealing with potential hurt feelings from grandmother about her sons' accounts, then we would probably continue to see her. You would just need to decide what to do with her previous balance.

That's a difficult situation. I focus on the delinquent account being discharged. Anyone who goes to collections shows they are not willing to even work with us on a payment plan, they don't care about us getting paid. If Johnny's account goes to collections, then his mother is told we are discharging them and that includes sister Sally, as it is the mother who also will not pay on Sally's accounting the future. I don't think mom would ever want to come after getting our collections letters anyway, and I don't think I've run into that situation. As soon as the issue comes up, they pay up or the pull all their kids and go elsewhere because we would DARE to ask them for money!

I know. This one is even more difficult given the grandmother has taken her granddaughter in who is the daughter of her son who she doesn't pay on. (this is Maine -- figuring out relatives is a little more difficult, lol).

I agree we should focus on the two delinquent accounts. Maybe not "take it out" on the 3 yo given it isn'ther fault she is in this family. And, she does have MaineCare, the number one insurance on the planet for the patient.

There was a user on here once (serene?) who mentioned a company whereby in order to set up a payment plan, they have to register their card so it automatically deducts a payment. It's easy to explain to them as you can tell them, "You know it is basically how your NetFlix, Verizon, and other accounts are set up. It works so much better as they have to do something "positive" either the card doesn't work or they delete that account. Then, it is easy to dismiss them right then. We certainly work with people on payment plans, but frequently what happens is they set up $25.00 a month, then they don't pay after three months.

My favorite thing to do is tell them we have no choice at this point but to send you to collections. We are willing to allow you pay half and wipe it all clean. $750 is certainly better than losing all $1500.

The other thing is this mother is very good at using passive-aggressive techniques.

A biller I hired about 3 years ago convinced me to try a new tack on this. Since we are a Peds practice, she figures 'the kids will get sick for sure at some point and they are going to need us'.
So, we don't turn anyone to collections for about 18 mo, no matter what they owe. The rationale is: if you send them to collections, you collect cents on the dollar anyway- if that. Versus, if they want to be seen, they have to pay at least part of their balance and we roll on from there.
After 18 mo of no response, we do turn them over to collections. (previous limit with us was 3 mo of no response).

The collections thing can be difficult. I remember a person on here when this came up before about the process of the four statements at least 30 days apart. I guess I wouldn't much worry about that.

Some practices actually get a credit card on file. I don't see our practice doing that.

While I'm sure this is universal in small practices, I think the issue is worse with Pediatric practices.

One reason is that often the parents are young and don't either have a lot of resources or understand the insurance/medical payment system.

Another reason is that Pediatricians in general are more forgiving than some other specialties (IMHO).

Medicaid for us is the easiest insurance. (Other than CHIPs patients) There are no copays and no deductibles. They probably have the lowest denial rate. They are also our largest insurance so they are more predictable. Many other physicians refuse to take Medicaid but 40% of all children in the country are under this insurance and many areas are higher. It's difficult in many areas not to take it. In Illinois they only pay about 60% of what private insurance pays but this is somewhat offset by it being easier.

Recently Illinois went into Medicaid Managed Care. It started out as 10 plans then dropped to 5, then they added back 2. Each plan has different rules and regulations and requires different information. While pushed by the federal government, it feels as though this was just to confuse, divide and conquer. I have patients who are switched in plans (some of which I do not take) without asking or notification but come in and can't be seen. Sometimes I will see them for free, sometimes I charge them, sometimes I turn them away. I have parents where siblings are assigned to different plans and are told they cannot change for a year. Truly a mess.

I try to set up payment plans when patients come in. We use the yellow sticky box to alert staff quickly to patients with a balance and they cannot make an appointment unless an agreement is made. If they pass on the appointment staff will note that in the yellow sticky. I will release records if they leave but make them come in to get them unless it is out of the area.

"If they want to be seen, they have to pay at least part of their balance and we roll on from there."

This tact can work, but it can also backfire. You see, they don't have to pay anything to be seen, and some of them know this, especially delinquent type people. You cannot refuse service or you are abandoning them. Also, if you say you have to pay to be seen, they can go online and say they were sick and you refused to pay without extorting more money for their illness. It's not pretty.

People who don't value your time... people who would rather pay a cell phone bill than you... people who buy cigarettes over paying you... do you really want these people in your practice?

If they refuse to at least set up a payment plan and pay something at the time, they will be dismissed properly.

Well mine is fixed. Thursday was the deadline for payment (just half the amount), so she transferred. I can't charge the Medicaid patient for records -- god no, can't do that. But, I can charge for her sons' records. At least I can get back around $100. I know she will complain I can't do that. But, I can. So many patients think the record is theirs. No it is the practices. They are entitled to a copy. Which they must pay for if we want to charge. And, we will.

After reading Wendell's post, healthcare is just so burdened with insurance. I wonder why. The hole way I fixing it was 10 days in the back room of Congress. I suppose the only way is universal healthcare. Part of that problem is a lot would pay for it and some wouldn't. This is probably stupid, but why not pay for the whole thing with a health sales tax. 3% across the board. It couldn't be more than the $700 I pay for my $5,000 deductible. And, then when patients who are getting assistance (which is good, and they pay better than my private insurance) come in with four smart phones and a Jaguar, it wouldn't be frustrating. It would mean that each phone was helping to pay for everyone's healthcare. Of course, then the government would set up all the rules. Only screening rule we need is being charged for routine ER visits.

Their answer is "medicare for all" which I'm afraid would not keep our doors open.

I find it fascinating that Medicare is the best payor in some states and the worst in others. Medicaid is rarely the best and often the worst, yet the future of America is largely dependent on it. This shows where our priorities are.

Big insurance and Big Pharma has corrupted the congress to give them what they want.

Hospitals are not flowing with money, (at least not in my neck of the woods). Physicians are certainly not. We are being paid to be secretaries who follow protocols.

Yet for profit insurance is doing well. Although Non-Profit, BCBS Illinois it paid 270 million cash to add 24 stories to a 33 story skyscraper in downtown Chicago. Why not spend the cash for delivering health care?

In Maine:

99213

Medicaid: $70.00
BC/BS: $72.29
Liberty Mutual: $104.00

99214 and 99214 are the same ratio. Plus Medicaid you never have a copay and they reimburse that fastest. Plus, we get a $60,000 bonus at the end of the year.

EMMC, our hospital, is loaded with money and over time, has bought around 10 hospitals and healthcare systems. The CEO and VP (two people), make about $750,000 and $550,000 respectively.

I would take a pay cut just to get rid of private insurance companies.

Do you need a partner? If I was paid those rates, I'd be in good shape

99213

Medicaid $46.56 (that's with a primary care bonus otherwise 39.xx)
BCBS $78.62
Aetna $83.99 I see very little Liberty Mutual so I picked a similar

Medicaid pays about the same ratio for '214s but pays almost the same for '214s and '215s to discourage people billing up.

I think it would be really helpful if people from some different areas of the country could post what Medicaid and BCBS pay for 99213 and 99214. You can thank the PPO's for these low rats. Still resisting in AK.

As to Wendell's comment, "Hospitals are not flowing with money, (at least not in my neck of the woods)".... around here they all cry poor but are RAKING it in. A relatively "poor" hospital in our area just announced a $480 million renovation.
Our hospital CEO salary... last news report I see says he got a 24% raise in 2012 to $1.6 million. I am guessing he has had sizable increases since then.

99213
Medicaid in Maryland $73.50
BC BS $59.36
Aetna $69.22


99214
Medicaid $108
BC BS $82.59
Aetna $102.17

I encourage others to post as well.

Now just for kicks.... take a guess what I get paid by Medicaid for a colonoscopy, done at the hospital or ASC

You can thank the AMA RVU cartel for the huge disparity between surgical reimbursement, which feeds hospitals, and office visits.

BCBS pays about 1200 to 1800 for colonoscopy here, but I think Medicare is just a few hundred. Likewise, a hip replacement is about 15,000 with BCBS (one surgeon is doing several a day) but $1500 medicare.

BCBS is our best payer. Until recently we could do labs through Quest and bill the patient for the labs, but the recently stopped allowing this. However, they cannot stop us for billing labs done in house, so many of us have purchased our own machines.

Thanks, Chris.
Again, not to hijack the thread, but I would be interested in other guesses...
Will be happy to post Medicare and BC/BS payments as well.

How about 100 dollars? Just a guess.

Alaska:
Denali Kid Care / Adult Medicaid
99213 119 / 116
99214 176 / 173

FLORIDA-PEDIATRICS

STAYWELL (MCAID HMO) / BCBS FL

99213 35.88 / 79.31
99214 53.19 / 103.91
99215 69.09 / 140.53

Chicago here, FP/Sports Med. We have been owed 28k on average a year and try to collect, have never used collections...in the past i was always afraid i would lose the patient, but honestly, they aren't paying me so who cares. Last year I instituted that if you had a large deductible or coinsurance and haven't met out of pocket we would collect 150 up front and bill fro the rest on a new problem/new patient visit...well guess what I put a dent in it and still ended up at abou 25K outstanding because i only covered 150 towards a patient who wasn't gonna pay.

This year i now collect ALL money upfront. we bill insuranc eand all money collected goes towards the deductible.

If you have a 500 dollar deductible and used 432 of it , we collect the remaining. if you have 500 and you ate it up but have 3000 out of pocket and 30% you owe, we collect 30% of the visit nd the brace and the injection and everything else.

We have had two people not wnat to see us, one filled out paper work in our office and walked out when asked for money before we took them back...everyone is warned on the phone and on email about this ahead of time with exact numbers as we run the insurance ahead of time.

But guess what, this jan/febaand so far march, i am not living month to month as far as my salary....

This is the way to go, and fire all people who won't pay.

we stoppped actively collectingb but when someone calls for an appt we know you still owe from 4 years ago and we let you know, you pay over the phone then we make an appt for you, if not, cya and go stiff someone else.

Wow Kris: Hour BCBS is paying more on a level 3 than you get on a level 5. I don't know how anyone can even keep the doors open with $35 for a level 3! Don't people realize our overhead, and that a plumber or car mechanic makes more than that!? I think I would go into a Direct Pay situation or Concierge if in your place.

Ketan: Yes, we required patients to pay in full until deductible met. Why shouldn't they? I certainly couldn't get my pickup back until I paid the $1500 for the brakes and rotors service. Does your staff have to check BCBS records for all this, call insurance co? What do you mean, "run" the insurance ahead of time? Patients usually don't know or confess what they owe.

Eventually, you will sculpt your practice to be mostly good paying folks. Sometimes a long-term patient gets in a bind and we write it off, but that's my choice.

" I don't know how anyone can even keep the doors open with $35 for a level 3!"
Maybe just bill as a level 5 ?\_(ツ)_/?
Just kidding, of course.

Certainly we are all wrong. I mean the 10 ten insurance company CEOs averaged 15.2 million over 2016. They must know a lot.

That 99215 is crazy. This brings us right back to the entitlement and CMS debate. The closest thing we have to a union is the AMA, which is why I don't belong. They do nothing. Our Maine Medical Society hosts picnics all summer. Our MMA is pretty good. Lots of policy stuff. Free legal advice, etc.

I think much of this is it would be so hard to stage a Medicaid and Medicare sit out. If all of the physicians in Maine stopped treating MaineCare, it would be less than a week before the EDs had to shut down. But, they would just pull out license and that's it.

As far as concierge, it's very difficult for a practice making $35.00 for a 99213 or anything for that matter. Probably has to see 30 patients a day of which 70% are likely Medicaid because they get seen for free. But, for instance, if I switched to concierge, about 1350 patients would have to leave, because they aren't going to stay and pay cash. The issue is it would be a huge gamble. But, there's no going back. You can't in six months try to get all those MaineCare patients back.

I may be wrong, but I think part of the discrepancies are what the governor chooses to do. We made around 40% of Medicare (it is based on Medicare at least for us). He changed it to around 72%. He also turned down the Federal funds. Millions. But, those were for expansion. So you expand, then the government stops with the money and now you have more on MaineCare with less money. I wouldn't be making it except for this governor.

Maybe just bill as a level 5 ?\_(ツ)_/?

Problem is Kris doesn't get enough on a level 5 to make it worth it.

I try to remember 25 minutes and 40 minutes. I often see a patient for something that isn't that difficult, but I end up spending over 25 minutes or 40 minutes or over. 99214 and 99215. Write the obligatory:

Spent 40 minutes with this patient > 50% of which was spent on counseling and coordination of care. And, you have an audit proof note.

And, just like writing the useless ADHD on Vyvanse scripts, what doctor would ever put 45%. It's a given they will write that. Just do away with it.

Nice thing about being solo with MaineCare is they pretty much don't audit you. They love your practice. The fact that you are seeing patients that would otherwise end up in more expensive EDs., etc. I am a little pickier with the private insurers.

Interesting to see what medicaid pays in other states.

Texas Medicaid:
99213 - $36.89
99214 - $51.80
BCBS:
99213 - $74.84
99214 - $110.08

However, for preventive 99391-99394, Medicaid pays more than some private insurance plans.

We also receive provider incentive payments for Mediciad MCOs for our patients have on-time checkups and other measures.

The $75.00 for an ear infection, bronchitis, sinusitis is fair. $36.89 is inappropriate. But, BC/BS lives by the co-pay. Say it is $25.00. They are now paying $50.00. Then with deductibles, they pay nothing most of the time.

So with PPO, you are required to charge only a low rate which insurance won't pay on anyway.

We are seeing more and more private insurance plans go toward deductible rather than a copay for sick office visits. Some even have deductible applied before copay. This makes benefits harder to check (now we have to call rather than depend on Availity/Navinet).