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You can give your staff strategies for effectively enforcing your practice’s payment policies.

Fam Pract Manag. 2002;9(5):19-20

Asking for and collecting money from patients is among the most difficult aspects of practice management, and the current economic downturn makes this task even more challenging.

The way your office staff handles payment problems with patients reflects on your entire practice, and the outcome can have a significant effect on your staff’s satisfaction and your bottom line. Here are a few tips for helping your staff manage difficult situations.

When patients don’t want to make their co-pays

Many patients do not understand that their insurance company’s reimbursement does not cover the full cost of care. Next time a patient says he doesn’t think he should have to pay you (“My insurance company pays you. Why do I have to pay too?”), it might help for you or your staff member to explain, for example, that the insurance company allows $42 for the service (despite the fact that your full fee is $50) and pays you $32 because the patient’s health insurance contract says he owes a $10 co-pay at each visit.

Your staff must make it clear to patients who refuse to make their co-payments that they are actually in violation of their contract with their insurance company. Pointing this out may help patients better understand your role in the process.

When patients say they can’t pay

Now that your staff has made it clear why the patient is responsible for paying, how can you help them collect from patients who say they can’t pay?

You and your staff have probably heard these excuses a million times: “I don’t have my checkbook [or cash or a credit card]” or “I lost my checkbook.” My personal favorite is “My checkbook [or wallet, etc.] is in my car. I’ll be right back,” followed by the sound of tires screeching in the parking lot as your patient makes a getaway.

Some of these situations are impossible to deal with. For example, I do not recommend having a staff member run after a speeding car to collect a co-pay. One strategy that does work well is to give these patients pre-addressed, stamped envelopes and tell them to mail their co-pay to the office. A few may scratch out the office name and address and use your postage-paid envelope to pay their electric bill, but our practice receives 96 percent of the envelopes back within two weeks, on average.

Your staff may want to ask patients who chronically resist paying at the time of service for their co-pay before you treat them. If they have left their means of payment in their car, this will give them time to get it.

Another good idea is to make sure your practice accepts credit cards. Credit cards have proven to be an important tool for collecting patient payments. Most patients have them, and they don’t have to be present to use them. For example, when a patient forgets to bring his wallet, checkbook and credit card to the visit, he can simply call you from home with a credit card number. It’s convenient for the patient, and it benefits the practice.

When patients want two visits for the price of one

I am sure your staff has experienced this scenario: Mrs. Jones brings little Jimmy in for his check-up. She brings Jessica and Stacey along too because they both have sore throats. “The doctor won’t mind,” she says, as she signs in all three children. You reluctantly consent to seeing all three patients and, after the encounter, give your office staff three superbills. But when Mrs. Jones learns she owes three co-payments, she loudly protests, “But we only had one appointment, so we should only owe one co-payment. I’m calling my insurance company and reporting you!” You know you are justified in billing for all three visits, but convincing Mrs. Jones of this is another matter.

The root of Mrs. Jones’ anger could be that she was unaware that she would be charged for each child. One way to help avoid this type of misunderstanding is to have your staff inform the parent before the children are seen that you can make room in the doctor’s schedule for all three children to be seen this time but that, according to the terms of her contract with her insurer, she will be responsible for paying each child’s co-payment. Letting her know this before the children are seen makes her responsible for making the decision and gives her the information she needs to make an informed choice.

When patients get angry

People who are angry and aggressive toward you or your staff are really fearful and insecure. They are afraid they won’t get what they need, so they confront you, guns blazing and tempers flaring, to get what they want. How can you help your staff handle them in a courteous, professional way while staying in control of their own emotions?

  • Train your staff to listen first. They should let the irate patient get his or her story out and blow off steam. Only after the patient has said his or her piece is he or she likely to be open to anything your staff may suggest. Intervene too soon and the patient may become even angrier because of the interruption. So train your staff to take a deep breath, step back and listen, encouraging them to avoid the temptation to match the patient’s anger with their own.

  • Once the patient has calmed down, your staff member should assure the patient. Have the staff person explain that he or she is listening, is concerned about the patient’s problem and will do everything that he or she reasonably can to help. If the problem can’t immediately be resolved, have your staff assure the patient that he or she will see to it that the problem is addressed and will notify the patient of the outcome.

  • Make sure your staff follows up with the patient. This is essential to keeping professional integrity – yours and your staff’s – intact. Trust is a big issue in medicine; both you and your staff need to show your patients that they can depend on your practice to help them.

  • Encourage your staff to not take the patient’s anger personally. In most cases, these patients’ behavior has everything to do with fear that they won’t get what they need. The combination of illness and insecurity almost always produces fear.

When enough is enough

How much difficulty does your staff have to endure to care for your patients sufficiently? If, despite gentle reminders and special efforts to collect amounts due, a patient still refuses to cooperate, it may be time to discharge him or her.

In our practice, we give careful consideration to whether we should discharge patients who exhibit the following behaviors:

  • Frequent disregard for our policies and procedures. Patients who constantly disrupt your practice not only make life difficult for you and your staff, but they also inconvenience those patients who do honor your policies.

  • Extreme rudeness to staff, especially profane language. When patients are sick, it is understandable that they sometimes have short fuses, but this doesn’t give them license to browbeat your staff.

  • Threats. You must take seriously any threats to any member of your clinical or office staff.

  • Illegal requests. This includes anything from requests for backdated work excuses to requests that you bill services or write prescriptions using a name other than the patient’s so that insurance will cover it.

Of course each of these scenarios should be taken into consideration on a case-by-case basis. Each patient is an individual and each situation is unique.

The patient discharge process usually entails notifying the patient by certified mail and sending a copy of the discharge letter by regular mail as well. Check with your practice counsel and the patient’s health plan for specific guidelines regarding notification requirements.

Put policies in writing

One strategy that may help you and your staff to avoid difficulties with patients is to inform them of all your policies and procedures (not just the financial ones) in writing, asking them to read and sign that they’ll consent to them. You can begin by including this in your admissions packet for new patients and make it a permanent part of each patient’s chart. If you come across a patient who wants services from your practice but refuses to sign your policies and procedures form, you may want to reevaluate that relationship. If the patient is already refusing to comply with one of the basic rules of your practice, you can expect future struggles down the road.

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Copyright © 2002 by the American Academy of Family Physicians.

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