Don’t allow patients to “cherry pick”

Most of our patients fall into two columns. The first we will title “head in the sand.” You know the type. They present as new patients or as existing ones with a new insurance card. On their initial visit as well as the first time they are seen each calendar year, they quickly glance over your financial policy and sign at the bottom.

I recommend updating your financial policy annually to create practice safeguards and to alert patients of changes prior to treating. Sample policies are available to members through the PPA library https://pinnaclepa.com/practice-engagement-program-pep/.

Inevitably, these same patients will receive a statement that clearly details “patient responsibility.” The outstanding balance may be a deductible that has not yet been met, separate DME deductible, co-insurance, or the ever so common “THEY said I was covered for those” orthotic balance. In many cases the first statement will be ignored so upon checking in for a follow-up visit the patient will be asked how they would like to pay their balance. To this question, the patient will often request that the previous visit(s) be “re-billed” to “see what happens.” These patients will take full advantage unless you control the situation (more on this in another Extra Extra).  

The next column we will call “cherry pickers.” These patients not only read the fine print of their insurance contract but believe they can manipulate coverage limitations and out of pocket expenses. For example: You treat a 45-year old male (referred by a member of his running club) with heel and arch pain who has tried several different OTC inserts and has iced and stretched with little relief for the past three months. He is excited to have a gait analysis (as you performed for his running buddy) and to be scanned for custom orthotics. Upon verification of benefits, it is determined that the patient has orthotic “coverage” and that his deductible has been met. It is unclear, however, if a separate DME deductible will apply.

Coverage information is relayed to the patient prior to scanning and upon reading your practice orthotic policy (this policy should include a required deposit regardless of “coverage” to initiate the fabrication process; sample orthotic policies are also available in the PEP library) the patient requests that his insurance NOT be billed for the orthotics as he believes he may have a separate DME deductible. . .    Sound familiar?

Although reasonable from the patient’s point of view, from a contractual standpoint it is not.  When providers sign payer contracts, it is with the understanding that any “covered” item or service listed on the fee schedule be billed to the payer.  Due to this contractual obligation, and the increased frequency of similar patient requests, the following is recommended. . .

  • Collect the orthotic deposit (with very few exceptions) at the time of scanning and explain your contractual obligation to the patient.
  • Bill the insurance and wait for the EOB to clearly reflect the allowed amount per unit and patient responsibility if applicable.
  • In the event (such as a separate DME deductible) that the allowed amount requires the patient to pay significantly more than your cash orthotic price, use your judgment and adjust the balance difference as a professional courtesy. By doing so you are abiding by your contractual obligation to the payer and the patient is still paying towards their deductible while feeling as if they have saved.

Please note: Adjustments of this kind should not become the standard in your practice, however in cases such as these, a professional courtesy can mean the difference between losing a patient and maintaining a positive referral source.

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