By Martine G. Brousse
Patient Advocate, AdvimedPro
January 11, 2022
Asked to pay your unmet deductible now?
In recent years, it has become common practice among medical providers to request the payment of your unmet deductible or out of pocket in advance, either for appointments early in the year, or before receiving services at a facility.
1. There are several reasons:
High deductibles and out of pocket liabilities (the amounts a patient must pay before an insurer pays medical costs in full) have become prevalent as ever larger costs are shifted to individuals and employees.
Changes mandated by the ACA ("Obamacare") profoundly affect the way medicine is to be practiced. Transforming this vast, complex and well-established system into a cost-effective, result-based model creates financial disruption. Uncertainty about the future of healthcare has created major anxiety, as many medical providers feel their livelihood and practice viability might be in jeopardy.
Reassessments of fee schedules by Medicare and commercial insurances, the downward federal budget allocation trend, rising operating costs and payment delays due to widespread technical system implementation issues have resulted in a shortage of income for many offices. Making do with less has become a daily game, finding new revenues an endless challenge.
2. The provider's point of view
Every billing department knows that, early in the year, patients pay off holiday credit card bills and taxes first. As an office might not want to refuse to treat patients with open balances, getting advance payments guarantees a minimum income during those leaner months.
Some specialties such as oncology have suffered significant reductions in reimbursements in recent years. Smaller practices in particular don't receive the bulk discounts from suppliers, extended payment deadlines or preferential insurance contract rates that larger entities enjoy. While waiting for patients to pay their balances, many must rely on lines of credit or savings to make ends meet.
Every January brings new insurance plans, changes in regulations and a significant amount of new patients, especially since the ACA implementation. The addition of staff to absorb this workload causes increased labor costs.
The implementation of the NSA federal mandate (see our blog "a new year and early gift) will likely result in a loss of income for many providers. Having no or few contracts with insurers had paid off... until now. If a physician renders a service at an In Network facility or under emergency conditions, the best reimbursement he/she can expect is an In Network rate lower than his/her charge, or to make a deal with the insurance. In either case, getting paid 100% as before is but a memory.
3. When to say no
If you have government issued coverage (Medicare, Medicaid), do not pay in advance! CMS, the governing administrator for Medicare, has ruled that a patient may not be asked for any upfront payment before a claim has been processed and the specific liability determined.
The only exception is the set office copay for Medicare Advantage or Tricare plans, due when services are rendered. Medicaid may also impose a share of cost to some patients.
Patients covered under a commercial plan and only scheduled for a minor office visit or service, should wait until they receive a statement, as it is unlikely they will meet their deductible. If the office cannot financially survive without that early contribution, better management might be in order.
Explain that you have already met your responsibility, or charges for other prior services are in process, to stop these demands.
4. In conclusion
If you agree or are forced to pay, ask for a cost estimate and offer a lower amount.
Always confirm the refund policy. Will any overpayment be held until applied to another open balance or be refunded? How fast would this take? Will it be automatic or will you have to ask?
When in doubt, or if you need help getting the office to back off, contact your insurance company. This behavior is frown upon, and sometimes prohibited by contract. A phone representative could call and demand the practice be stopped.
@ Martine G. Brousse 2022