Determining Patient Fees

In today's managed care climate, ambulatory care settings have many different arrangements with insurance carriers and with their patients. Often, the office or urgent care center will have a contract with HMO-type insurance carriers in which they agree to a specific fee for certain procedures. In this instance, the physicians of the center are usually known as participating providers. In some plans, the patient pays what is known as a copay amount for each visit. In other situations, the patient is liable for a certain percentage of the fee. This is usually known as coinsurance. Ambulatory care centers may also accept Medicare and Medicaid patients, usually for a predetermined fee.    

The situations for payment are numerous and varied, and in this unit will examine them in greater detail. Of critical importance at the onset of the patient relationship, however, is that both patient and physician have an understanding of their fiscal responsibility to each other. The patient must also be made aware of any fees imposed for missed appointments, telephone consultation, and other charges the patient may not anticipate. It is not unethical to charge for these, but it is not recommended without prior notification to the patient.    

Usual, Reasonable, and Customary Fees  
A fee schedule often used by Medicare and some insurance carriers is referred to as usual, reasonable, and customary fees. Usual refers to the fee typically charged by a physician for certain procedures; reasonable refers to the midrange of fees charged for this procedure; and customary is based on the average charge for a specific procedure by all physicians practicing the same specialty in a defined geographic region.   

Discussion of Fees    
The manner in which billing and a discussion of fees is addressed will vary depending on the type of medical facility, the needs of the practice, and the professional services rendered. Years ago, personnel     in medical facilities would typically ask patients at the end of their visits if they would like to pay then or be billed later. It is now customary and in some offices mandatory to request payment at the time of service. Today, the fee for the visit is simply stated, and if a person does not have cash or a check, the option of credit card payment is often provided. If a patient is a member of an HMO, and the ambulatory care setting is a member of that HMO, then the patient is typically responsible only for any established copay amount.

Inherent to the total billing process is the necessity of initially establishing a fee schedule and informing patients of charges and exactly what portion of the bill they are expected to pay. Ideally, the patient should be told the approximate cost of the procedures at the start of treatment. Charges for some daily routine visits may be submitted to the insurance carrier, and the office may not know what portion is covered until information is received from the carrier. The facility may accept numerous insurance plans and participation in these plans determines the amount that the patient owes. Many misunderstandings will be prevented and subsequent collection of delinquent accounts expedited when the office staff is well informed about insurance reimbursement and carefully explains fees to the patients.

Adjustment of Fees    
If another physician or health professional is provided a service through the office, professional courtesy may be extended. This may mean providing a service free of charge, or at a discount of 2 to 50 percent, as determined by office policy, when treating a physician or an allied health professional. If the physician or other professional has health insurance, the office may choose to use it to cover the service. In certain cases, the physician in charge of the office may prefer to extend total professional courtesy. However, in today's health care climate, it is rare for an office to totally refuse to accept insurance payments. Discounts, less commonly, may also be extended to clergy, pharmacists, and dentists.    
Other adjustments may be made for patients with limited income. For example, if a patient had been going to the ambulatory care center for many years, but recently lost a job or ran into unfortunate financial circumstances, the physician may ''write off," a portion of the bill. This sum will be written off against the physician's income, and the patient will not have to pay any amount or will pay a reduced amount according to what is affordable. This courtesy usually applies to only existing patients and is not offered to new patients.    
Adjustments also may occur with Medicare, Medicaid, Blue Shield, and private health insurance patients. Physicians who accept assignment in these programs agree to accept what the insurer allows. For instance, a fee of $150 may be charged, but $95 is accepted as payment in full by the provider. The remainder of the bill, $55, is written off so that the patient is not responsible for this remainder of the fee.    
Medical assistants must be aware, however, of the pitfalls of adjusting or reducing fees. It is difficult to accept all hardship cases and still remain a viable practice. It is always a helpful resource to patients who cannot pay to be given the names and telephone numbers of local health care clinics that may be able to accept them as patients on a sliding scale or no-fee basis.    
Credit Arrangements    
If the patient will need to pay a substantial out-of-pocket amount, it is helpful to make the patient aware of this and discuss different credit arrangements that can be made. Many ambulatory care settings will work out installment payments, usually without finance charges, to spread the cost of services over a pre-agreed period of time. This eases the financial burden on the patient and also makes it more likely that the office will be able to collect monies due.