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Your front desk's role in reimbursement


"Covered" is not the same as "paid"."Accepting" an insurance plan is not the same as "participating" with an insurance plan. Pay attention to individual vs. Family deductible and out-of-pocket status. Make sure that patients understand that a quote of benefits is not a guarantee of coverage.

Make sure that patients understand how and when you expect them to pay.

You should always try to collect the full amount due for each visit at the time of service.

Consider accepting a post-dated check if the patient says that they don’t get paid until Friday.

Accept credit cards. Only consider prolonged payment plans as a last resort.

Make it clear to patients that their insurance carrier requires you to collect and them to pay all copays and deductibles. Only allow financial hardship discounts for patients who have truly demonstrated it.

Do not be embarrassed to ask for the payment that is rightly due.

The cashier at the grocery store is not embarrassed to ask you to pay for your groceries. Be friendly, but firm when asking for payment. Create an expectation that the patient will pay what they owe on time-not what they feel like when they feel like if at all.

Make sure that you have a clear and concise financial policy statement that spells out what conditions need to be met for financial hardship, and what documentation the patient is required to present in order to prove it. Not wanting to pay the bill is not the same as being truly unable to pay the bill. If they pay $80 per month for Direct TV, they can cancel that and pay their copay instead.

Also, patients’ financial situations often change. Just because the patient is going through a divorce and lost their job today doesn’t mean that they won’t have won the lottery and married a millionaire next month. For patients who claim to have ongoing financial hardship, require that they continue to prove so (consider reviewing their financial situation on a regular basis).

Also, 100% financial hardship write-offs may rarely be warranted. Most patients can pay some portion of their balance. No insurance plan will be understanding of a financial hardship write-off if a patient goes to an out-of-network provider and owes $80 per visit instead of going to an in-network provider and owing $10 per visit and then is approved for financial hardship.

If patients balk about having to pay, remind them that they have agreed to their arrangement/terms with their insurance plan, and that you are required by contract/legal obligation to collect them. Even if the entire claim is applied to an out-of-network the deductible, not collecting that deductible amount from the patient would result in the claim being considered a false claim as your charges would have been misrepresented to the insurance carrier. The patient has agreed (with their insurance plan) to meet their financial obligations spelled out within it. You have agreed to provide truthful information to the carrier about the services rendered, the patient’s condition and your true charges for the services. Provide a truth in lending statement to all patients who establish a payment plan and only offer payment plans to patients with larger balances who truly cannot pay at the time of service. Using coupon booklets can help patients stick to payment plans. Make payment plan terms reasonable. In other words, if a patient owes $600, do not allow them to pay you $1 per month for 600 months. Suggest $200 per month for 3 months. This addresses many patients’ excuses for not paying. "I don’t have any cash on me." "I forgot my check book." "I don’t get paid until Friday". "If I pay this amount, I won’t be able to pay my XYZ bill on time." A post-dated check is better than letting the patient leave the office without paying anything. If this is not possible, collect at least a portion of the amount due and make sure that patient understands that you expect the balance to be paid by the next visit at the latest (Ex. Patient has a $20 copay, but only has $10 in cash and doesn’t have her check book with her. Collect the $10 and make it clear that $30 will be due at the next appointment.).Do not give patients an option to pay now or later. They will almost always choose "later". Let them know before services are rendered that you expect payment at the time of service and that their responsibility will be collected directly following their visit. If at all possible, let them know what their insurance carrier has stated they will owe, and what kind of payment methods you accept before they come into the office. Many patients "feel" that if a health care provider doesn’t tell them that a service is not covered or that their copayment increases and you don’t notify them at the time of service that they should not be held responsible. You need to let patients know that they are responsible for knowing their benefits, for any deductible/copay/coinsurance responsibility and non-covered services (regardless of whether the provider informs them of it or not), and that they should refer to their summary plan description or certificate of coverage to confirm their benefits. Some plans have both individual and family deductibles and out-of-pocket maximums. If the patient has not met their individual deductible, but other members of the family have already satisfied the family deductible, the patient’s claims will not have any deductible amount applied to them. Accepting an insurance plan just means that you are willing to bill the plan. Participating with an insurance plan means that you are an in-network provider, that you agree to abide by the plans rules and limitations, and that you are willing to accept the contracted/allowed amount of the plan as payment in full for covered services. Many patients will ask if you "take" their insurance, but often mean to ask if you participate with their plan. A patient’s plan may cover physical therapy, but the patient may have a $5,000 deductible. It’s important to make sure that patients understand the difference.


Deductible- the amount on covered services that an insured must pay toward covered benefits before the insurance carrier/plan begins paying

Copayment (Copay)- the dollar amount that a patient must pay toward a covered medical service (usually used to refer to a flat dollar financial responsibility-ex. $20 per visit)

Coinsurance- the percentage that a patient must pay toward a covered medical service (usually used to refer to a percentage of an allowed amount or billed amount for which the patient is responsible-ex. 20% of the allowed amount)

Covered Service- service to which insurance benefits apply

Non-covered Service- service for which the patient has no insurance benefits and must pay for at the full billed amount

Stop loss or out-of-pocket maximum- amount that a patient must pay before the insurance plan pays covered services at 100% (limits the out-of pocket expenses that a patient/family can incur in any benefit period)

Are there any guidlines for using modifier 59?
59 Distinct Procedural Service
Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.