Managing a Patient's Pocketbook

by William D. Esteb

About the time a patient is feeling better and considering discontinuing care, he or she receives a bill for care that was rendered weeks earlier. Rejected by the insurance company, the bill now goes to the patient. And they're angry. Do patients blame their shortsighted insurance carrier? No. They blame you. Because when you accepted insurance assignment you implicitly assumed the responsibility to be a good steward. As a crowning touch to their chiropractic experience they are left with the perception that you have been irresponsible by mismanaging their finances.

Whether it is the result of not paying attention or depending too heavily on reimbursement from third-party payers--pushing each patient's policy to the limit with a super-duper "this-will-get-'em-to-extend-coverage" narrative--the bottom line becomes patient dissatisfaction. When you accept direct payment, you assume the obligation to responsibly monitor the proceedings. Returning to the customer to collect an outstanding balance may work for Pentagon defense contractors, but in chiropractic it leaves the patient with a bad taste in their mouth. Instead of extolling the virtues of chiropractic, they feel double-crossed, thinking they have chosen an incompetent businessperson.

One way to prevent insurance surprises like this is to uncover the formula that each major carrier uses as a basis for honoring claims. Do a little research and find out what each company pays for different types of diagnoses. Do they typically reject the claims at the 15, 20, or 30 visit mark, or do they look at the dollar amount? Find out. See if there's a pattern. Then when patients begin care, draw a red line on their travel card at the visit number where their particular insurance company is likely to balk. In fact, show it to the patient so they understand what will happen and explain why they can't use their insurance carrier's willingness to pay as an indicator of how much care they need. As their treatment reaches the red line, let them know. When it is reached, explain that you'll continue to submit the bills, but they will need to start assuming payment for their care.

Bring your checkbook

Many offices take this a step further by sticking to a policy by which patients, after swiftly fulfilling their deductible, must pay their co-payment on every visit. Patients become accustomed to bringing their checkbooks to your office, just as they would for a haircut, a meal, or getting their car serviced. This also helps combat the perception that care during the Initial Intensive phase of care is "free" because there isn't a direct exchange of money.

This mismanagement is often reflected in collections. Chiropractic is one of the few businesses that has practically institutionalized the idea that there should be a discrepancy, even a large one, between services and collections. Just as poor compliance is the result of inadequate patient education, poor collections are often the result of poor financial education. Combine this with vague or inconsistent policies, and the staff's effectiveness is undermined.

This problem is especially frequent among doctors who have a "soft touch." Whether suffering from low self-esteem or just from being easily manipulated by patients, these doctors modify the financial arrangements privately with each patient. Some even depend on the patient to communicate the arrangements to the staff! And while few offices barter chickens or apple pies for chiropractic care, patient ledgers in these offices uncover a wide variety of fee structures. Not only is this a great way to sabotage your staff, it's a great way to end up in jail! No wonder staff members have difficulty collecting fees!

Offices with high collection ratios run their practice like the business it is. That doesn't mean they expect 100% collections; however, they expect patients to be financially responsible. Forget your checkbook? "No problem, we'll be open for another four hours." Or, "Your outstanding balance has reached $XX, and our policy prevents me from scheduling another appointment for you until your financial obligation has been cleared up." These offices empower their staff by setting exact policies which are communicated to patients and consistently administered. No surprises.

Is there room for hardship cases? Of course. Can you give your services away? By all means. Get involved with the homeless or the destitute and donate everything. A doctor in Yakima, Washington treasures his pro bono work treating migrant workers. Besides the joy of serving in this way, he's starting to pick up some Spanish! The point is to consciously set a financial policy and stick to it. Rise above the notion that if there's money in the checkbook and they haven't come to take away your toys, you're in good shape. Those who merely want to be able to pay the bills seldom find themselves doing anything else. This severely limits their influence in their community.

Could your staff afford care?

A collection problem that often extends beyond the lack of consistent policy, and one that is seldom mentioned, is the staff member who thinks the fees charged by the office are too high. This is an attitude usually found among those who have difficulty collecting money. Staff members, paid just a few notches above minimum wage, imagine how difficult it would be for themselves to pay for the recommended care, and find it easy to side with the financial difficulties expressed by patients.

Perhaps staff members bring this attitude with them when they start their job because the word on the street is that chiropractic care is expensive. And frankly, heavily influenced by the sickness-oriented insurance industry, chiropractic is too expensive. For the more than 37 million Americans without health insurance, chiropractic is an expensive proposition. This number will continue to rise as HMOs and PPOs unwittingly suck in more and more businesses keen on cutting health care costs.

Another distortion is caused by the fact that doctors and staff members receive their care for free. It's easy to fit preventive chiropractic care into your lifestyle when it's free. It's easy to philosophically assert that adjustments are worth a million dollars when you don't have to write a check for yours. And it's easy to forget to create an affordable post-insurance, post-symptomatic fee structure in your office when, once a week or so, you're getting your care without any impact to your household budget. Offices that greedily take every dime an insurance company will dole out, without creating a policy that makes non-symptomatic wellness care affordable, have made wellness care elitist and beyond the reach of the average patient. Inadvertently, these offices practice medicine, forcing patients to play the insurance game of inventing a new problem every 90 days or so.

Chiropractic worked hard to be recognized by the insurance industry. Will "dancing with the devil" be its ultimate downfall? Ask the stressed-out doctors with high overheads who got addicted to the easy insurance money of the 1980s.

Buy the book
A Patient's Point of View
Originally published in 1992
240 Pages
US $19.95

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