These are difficult economic times, not only for patients but for physician practices.
Most patients do their best to pay their bills, and doctors and hospitals do their best to institute reasonable payment plans.
However despite all the help that’s offered, there is a small proportion of patients who “brazenly withhold payment as if they can do it with impunity.”
Sending delinquent accounts to collections is often the choice of last resort. “I think it just feels wrong,” says this urologist, adding, “as a human being, I can understand that difficult choices that many people face in deciding where to spend their hard earned yet meager wages.”
But sometimes there’s no choice, and it’s a step done very reluctantly by the medical community.
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{ 15 comments }
When I entered private practice 20 years ago, I was amazed at how many people simply decided not to pay their doctor even while buying themselves toys. Others couldn’t pay because of the very illness that brought them in of course. Most who didn’t pay were just deadbeats however. I turned them over to collections as per practice management consultant recommendations.
I didn’t like the way it worked out. They either didn’t get anything out of them either or cheated me–less than 2 % came back. I resolved to never turn anyone over to collections again. I think cash on the barrel head up front is a better policy for me. If they can’t afford the care and I want to treat them anyway, then I prefer to offer a reduced rater that will still be due at (or before) the time of service. I don’t like being their doctor and creditor too.
Now everyone who is good for it (and many who aren’t) have a credit card anyway. They can charge it and someone else be the creditor.
Responsible and ethical people know it is their obligation to pay their bills on time. At the same time, misfortune and hardship can hit anyone, and it is possible that with the best intentions otherwise, a person cannot pay a bill when expected. That being the case, It is still that person’s obligation to contact their creditor at once, not after months of bills and past-due notices, and attempt to construct a payment plan that shows a good-faith effort to honor their debts. Failure to do that is on its face bad faith. Ignoring bills is bad faith.
Unlike service providers like utilities, who can force the process by cutting off service, all a medical practice can do is refuse further appointments or terminate a patient from care for failure unless it chooses to go the ways of collections or court. You can’t repossess an office visit or a procedure.
I have found the collections process to be not very helpful. The recovery rate is low, and for the most part, my observations see them as mostly pickers of the low-hanging fruit, and that’s about all. Alternatives like small-claims court, for a doctor, are fraught with negatives; frequently the defendants are indigent, bankrupt or similarly insolvent, and patients can be vindictive when subjected to litigation, even when they have thwarted all milder efforts at settlement. There are some people who really do think they don’t have to pay their bills if they don’t feel like it, and too frequently, they get away with it. Attaching liens to someone’s house is no way to run a practice.
I don’t think it’s wrong to send delinquent accounts to collections. After all, money is still owed and has to be collected in some fashion. A medical provider cannot just send out monthly bills forever. Either they take the loss, or they sell it to a collections agency and get some of their money.
However, my experience (3 major hospitalizations in 3 years plus dozens of other tests and procedures) tells me that doctors and especially hospitals are very quick to send things to collections. I’ve had several things sent to collections, unfortunately, and in each case it was due to errors on both the hospitals and insurance companies. All the back and forth between the three of us caused unnecessary delays, resulting in the hospitals just deciding that it was my problem and sent the bill to collections. So, I think some leniency, particularly if the patient is insured and cooperative, is definitely in order.
This post made me think of a couple things:
1) My experience is that physicians often don’t discuss financial arrangements with patients prior to giving treatment. As a dentist I have a much more procedure driven office than most primary care offices. I find it very helpful to explain to the patient what the procedure or service will cost prior to the delivery of the care so that the patient can make an informed financial decision. My experience is that this isn’t done in most medical situations (doctors’ offices and hospitals).
2) Many medical settings that I’ve been in aren’t able or willing to accept the little green rectangles from my wallet at the time of the appointment. They will not estimate my portion and wait for insurance to pay. Then they send a bill. This happened to me today at the podiatrist’s office. I’ve had two office visits and a set of orthotics delivered and each time they wouldn’t take my money because they didn’t know how much my insurance would pay. I’ll pay the bill when I get it, but a lot of folks have long since forgotten about their treatment by the time they get their bill. That horse is already out of the barn!
I agree that collection agencies are the last resort and I’ve had poor results with them.
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2) Many medical settings that I’ve been in aren’t able or willing to accept the little green rectangles from my wallet at the time of the appointment. They will not estimate my portion and wait for insurance to pay. Then they send a bill. This happened to me today at the podiatrist’s office. I’ve had two office visits and a set of orthotics delivered and each time they wouldn’t take my money because they didn’t know how much my insurance would pay. I’ll pay the bill when I get it, but a lot of folks have long since forgotten about their treatment by the time they get their bill. That horse is already out of the barn!”
This is very true!
Also, I have had experiences with Cedars-Sinai where they say “It’ll be $932 today if you want to pay for the MRI. If your insurance company finds a way to deny it, you’ll owe $5k. Do you want to pay upfront?” Then after paying cash, their billing office wouldn’t give me the insurance-required superbill with codes so that I could file for reimbursement from my insurance, thus denied. I’ve had it happen with two MRIs and also a Growth Hormone Stimulation test.
It really, really hurts the pocketbook when you are disabled and unable to work to begin with.
I don’t think it is wrong to send unpaid bills to a collector. Usually that is the end result of several written requests and notices and usually a notice of termination for non-payment. No one has a right to expect a creditor to forget about money owed.
But I have found the collections process futile. The recovery rates are so poor as to make the effort not worth the time. And when the rare case of a debtor wanting to make payment for service occurs, once a collector is contracted, even if they make no effort to collect, they are still due their percentage.
I agree with the poster above. Your energies are best devoted to prevention. Verify insurance. Hold your staff accountable for failing to do this. Insist on deposits whenever there are issues of ineligibility or inability to confirm. Have as much protective language in your practice paperwork as is allowed to pursur other payment as in credit card payment and interest on unpaid charges. Make sure you have accurate and up-to-date demographic information. Verify employment if claimed.
I stopped sending patients to collection for two reasons
1: The return rate was pitiful
2: I have had experience on other side of the coin with these guys. Specifically someone with my name (different middle initial) who had unpaid debts. I would get phone calls asking my name then discussing my “debt”. I would point out they had the wrong person (including wrong middle initial) and more often than not deal with abusive responses. Folks, the people who work for these companies can be real jerks. It doesn’t matter whether they have the right person the just want $$$. Finally, when insisting on talking with a supervisor (if I was not hung up on which happened 75% of the time). I would get removed from the list. Then in two weeks I would get calls from another collection agency. The same thing would start all over again. This has gone on for more than two years. Yes people should pay there bills, but given their pathetic reimbursement to you and their abusive nature when dealing with ANYBODY (from loser to upstanding citizen having a hard time, or even the wrong person as in my case) is this who you want collectng money in your good name? I think not. IMO most people will try to work out a payment plan if you call. For the chronic non-payers, give a 30 day written certified notice (with cause) and terminate the relationship.
Bills I’ve received for medical care since the late 1990s have been pretty much indecipherable. Though I’ve never been delinquent in payment, I also can’t say I understood what I was paying for. So, to some extent I think clearer statements — less coding, fewer abbreviations, etc. – might encourage some to take their bills more seriously. I absolutely agree that the interaction between insurer and provider makes the process terribly confusing for the patient.
Both non-profit hospitals in this town received national negative publicity several years ago for excessive use of body attachments. Afterwards, they seemed to make a greater effort to at least help patients understand financial aid options available to them — and have made that a central component of their marketing campaigns ever since. I suppose there’s some advertising value to being kind and charitable, if you want to go that route.
Recently Johns Hopkins has received some unfair bad press in The Baltimore Sun about suing patients for unpaid medical bills, but in their response they clearly do this for a small, small percentage of patients meanwhile they provide considerable uncompensated charity care.
Just because a physician goes after money owed aggressively should not imply that they are cold, callus, Scrooges. Many of us, rural primary care docs, are just trying to pay our bills too.
I blogged on the Johns Hopkins experience last week at The Country Doc Report. (http://thecountrydocreport.wordpress.com/2008/12/23/hospitals-doctors-struggle-with-how-far-to-go-to-collect/)
What truly galls me is the increasing number of folks who enter the office, resplendent in furs and jewelry, and fight with the desk over a 20 dollar copayment. Folks can pay 50 dollars for manicure and pedicure but somehow have a problem with paying the doctor bill. OK I’m done now.
When evaluating whether or not to send a patient to collections, a physician must first be absolutely certain that he or she is not guilty of patient abandonment.
Sadly, many patients are unilaterally terminated by physicians who “brazenly withhold services as if they can do it with impunity.” And, because most patients are entirely unaware that abandonment is considered medical malpractice, the proportion of physicians who engage in this practice is quite large compared to patients who are negligent about medical bills.
In my experience, as both a medical professional and consumer, patients who ignore the doctor-patient agreement and do not pay their bills do so because they do not have the money. On the other hand, physicians who ignore the doctor-patient agreement and unilaterally/abruptly terminate patients without providing adequate referrals do so because they do not have the empathy. (Most doctors will substitute “empathy” with “time,” but this still means that these physicians feel as though they should not be forced to spend any time helping a patient find appropriate care if they’re not being paid for that time – regardless of what the AMA or the courts have to say about the matter.)
If physicians do not start acting like healers instead of acting like dealers, then trust in the profession will never be restored, and more of these educated “consumers” will begin to realize that they’ve been victims of a type of medical malpractice they never knew existed.
Or, because physicians think with their wallets instead of their hearts, think about it this way: a few hundred dollars from collections will never be worth the outstanding costs associated with a medical malpractice lawsuit.
What often happens is the hospital gets aggressive and gets paid while the doc gets nothing.
The Medical Office should be responsible for verifying the following before sending a patient to an outside collection agency:
1. The patient was actually treated that day
2. The procedure codes were billed correctly
3. health insurance processed their payment
4. The patient truly has an outstanding balance
5. Several statements and a patient phone call (or 2,3) was attempted.
**It’s always nice to send a pre-collection letter or two as a last attempt.
If no response from the patient then it is OK to send them to an outside collection agency.
I have been through 35 surgeries and counting for the last twenty years living on very small fixed income. Below the poverty line. My insurance covers most but even trying to afford 40 dollars is like a thousand to me. The difference between eating and starving. Folks i got to tell you from my perspective being poor and disabled is no fun. Sick with hep c stage 4 chronic cirrhosis and needing a knee replacement just to mention two of the many things wrong with me that keep me from functioning in a work environment. I got the hep c from a blood transfusion back in 1988 before they screened the supply. Ok a brief synopsis of me. I love my country and consider myself a patriotic God fearing man. When i see the horrors of the medical/insurance community and how the poor is treated i almost lose faith in humanity. You all who have money better be on your knees and thanking the Lord above that you can afford health care and the ability to be able to work and i would advise anyone to think twice before they cast judgment from there high places on the poor and sick. Wow the arrogance. At least in Canada they take care of the sick no matter who it is for free. Ohh they say high taxes, it already is here. They say ohh you will have to wait to see someone. I wait two months to see my doc. This will eventually unravel even as we speak the system here is falling apart from greed and hypocrosy. I recently could not pay my Doctor bill of 45 dollars. The bill lady said i am sorry sir we will just have to let you go. After years of paying and struggling to the core they just dropped me like i was no one. I pray that doctors will remember why they became doctors. Not to be rich or glamorous but to help the sick and dying. God bless us please and help us all try to be more civil.
I’ve worked in the medical field as a biller for over 25 years and have seen my fair share of patients who simple do not want to pay their bills……whether it is copayments, coinsurance or deductibles. Many of them simply don’t understand their schedule of benefits with their insurance companies or know what their financial responsibility is going to be. Some of them “work” the system by making claims that it is the staffs responsibility to inform them and if they don’t, they don’t pay. The remainder are simply deadbeats. There is a small percentage that truly do have financial hardship and this needs to be proven with financial statements etc. The mindset of most patients is that the doctors make plenty of money and can just “write it off” which is far from the truth, not to mention fraudulent. We have so many patients that have received 6 or 7 statements, 2 collection letters and several phone calls and never return our calls UNTIL AFTER they have been turned over to a collection agency and then call us (usually very angry) and wonder why they were turned over. Most medical offices, including mine, are more than willing to work out payment arrangements but the majority of patients never call to arrange this or don’t return our calls when trying to reach them. If they do set up arrangements, they usually default on them.
I am all for using a collection agency after all means to collect from the billing department have failed. The practice I work for adds on a collection fee that covers our percentage that the agency would keep and we usually wind up collecting 100% of the balance. Those who don’t pay….well it shows up on their credit report, probably along with the all their other unpaid bills.
We do our best to inform patients of their benefits and estimated financial responsibility prior to procedures being done but it is ultimately THE PATIENT’S RESPONSIBILITY TO KNOW WHAT THEIR BENEFITS ARE.
Physicians went through all those years of schooling to practice medicine, not to be creditors.
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