You take the good; you take the bad. You take ’em both, and you have healthcare reform. Like most government-led initiatives, healthcare reform in general—and the Affordable Care Act (ACA) in particular—has inspired a lot of passionate debate. And that’s because, while it has expanded health coverage to millions of previously uninsured people (woo-hoo!), it also has given way to some less-than-positive consequences. One such effect: the trend toward increased patient financial responsibility (whomp, whomp).

Speech-Language Pathologist Salary Guide - Regular BannerSpeech-Language Pathologist Salary Guide - Small Banner

Out-of-Pocket Overload

In fact, as this CNBC story reports, the average deductible for a bronze plan from the federal healthcare exchange in 2015 was $5,181 for an individual and $10,545 for a family. Silver plans—which, according to CNBC, are “by far the most popular plans sold on those exchanges”—had average deductibles of $2,927 for individuals and $6,010 for families in 2015. And the growing popularity of high-deductible plans (HDHPs) isn’t limited to the federal exchange: as Brooke Murphy writes in this Becker’s Hospital Review article, in 2015, “more than 24 percent of individuals participating in employer-sponsored coverage chose HDHPs, up from 20 percent in 2014.” The article also notes a study showing that “44 percent of employers are expected to offer HDHP as the only benefit option for employees within the next three years.”   

Bad-Debt Blues

And while that trend is far from ideal for the patients themselves—hello, sticker shock—many folks forget about the party on the other side of the financial equation: healthcare providers. After all, when patients fail to hold up their end of the bargain—that is, pay their coinsurances and copays—healthcare providers are left to eat the cost. “Patients who receive services may be unable or unwilling to pay their high deductibles, driving bad debt and charity care at health systems nationwide as reimbursement rates drop,” Murphy explained.

Loopholes and Losses

Furthermore, thanks to ACA loopholes, “insurers are obligated to give a three-month grace period for policy premium payments,” NextGen explains in this resource. So, if a patient misses a premium payment, the insurer is legally required to keep the coverage active for three months from the date of the missed payment. The catch: the insurer is only required to pay benefits during the first month of premium delinquency. After that, while the patient is still technically “covered,” the plan is allowed to:

  • Hold off on paying claims until the patient pays the premium owed.
  • Deny all claims for services provided during the second and third months of delinquency (if the patient never pays the balance owed to the plan).

At that point, providers can seek payment from the patient directly, but if you have any experience with collections, you know how much of an uphill battle that can be. Perhaps the craziest part of the deal: patients who fail to pay outstanding balances with their insurers can enroll in new plans as soon as the next open enrollment period begins.

Payment Protection Plan

What does all of this mean for providers (PTs, OTs, and SLPs included)? It means it pays—literally—to be extra vigilant about streamlining and optimizing your entire billing process, from the moment a patient calls to schedule an appointment to the minute you send a claim out the door. Specifically, I recommend:

1. Completing in-depth insurance verification checks for each patient.

This means doing more than merely confirming that your practice accepts a patient’s insurance. You also should determine whether the patient’s plan places any out-of-pocket financial responsibility directly on the patient—and if so, how much. That way, you can inform the patient of the exact amount he or she will owe upfront. You also may be able to estimate the degree to which the patient’s plan will cover the services billed—though this certainly will require you to dig deeper into the details of the plan. However, as Erica McDermott explains in this blog post, “While cost estimation does require some legwork, the benefits—which include improving upfront collection, boosting patient satisfaction, and minimizing days in accounts receivable—are worth it.”

2. Submitting claims in a timely manner.

I’m not just talking about complying with each insurance carrier’s timely filing requirements. If a patient loses coverage—for not paying the premium, for example—you’ll want to know as soon as possible so you can adjust the amount you collect from the patient at the time of service (see item three below). That means getting claims out the door fast, because letting ’em pile up could lead to mass denials several months down the road. And while we’re on the subject of denials: if you’re denied payment, make sure you promptly investigate the cause to determine whether the patient did, in fact, lose coverage.

3. Collecting patient payments upfront.

As McDermott writes in the previously cited post, “only 21% of patient balances that aren’t collected at the point-of-service are ever collected.” I don’t know about you, but I don’t like those odds. To stack the deck in your financial favor, you’ve got to collect patient payments at the time of service. If your practice is struggling to make that happen, check out this blog post to learn tried-and-true strategies for optimizing your collections process.

Like most pieces of reform legislation, the ACA was the product of a lot of give-and-take. And unfortunately, that means some of its effects have been less positive than others. But, challenges are a fact of life, and as good ol’ Mrs. Garrett would say, there’s no need to feel helpless in the face of adversity: “Take some action; help yourself.”

Have you experienced any significant changes in your clinic in the years since ACA adoption? If so, how did you adjust? Share your thoughts in the comment section below.

  • The PT Patient's Guide to Understanding Insurance Image

    downloadApr 3, 2017

    The PT Patient's Guide to Understanding Insurance

    Patients are shouldering a greater portion of their healthcare costs than ever before. But when they don’t know the specifics of their coverage, they can end up with much bigger bills than they bargained for—and that often leads to unpaid balances and unfinished treatment plans. Bring them up to speed—and improve your practice’s collections and patient retention—with this guide. Patients will learn: What it means for a service to be “covered.” How to define common insurance terms. …

  • Suppressing Sticker Shock: How to Handle Your Patients’ High-Deductible Health Plans Image

    webinarFeb 23, 2017

    Suppressing Sticker Shock: How to Handle Your Patients’ High-Deductible Health Plans

    Copayments, coinsurances, unresolved balances—oh my! Any one of these can cause headaches for healthcare providers, but as healthcare reform efforts shift more and more financial burden to insurance beneficiaries, today’s practitioners are increasingly facing all three. And these challenges are not only hurting their patient acquisition and retention rates, but also their bottom lines. Tired of spending time verifying benefits only to lose those patients to copay sticker shock? Stuck in a constant cycle of pursuing past-due …

  • Common Questions from Our Patient Sticker Shock Webinar Image

    articleMar 31, 2017 | 33 min. read

    Common Questions from Our Patient Sticker Shock Webinar

    From copays and deductibles to payer contracts and benefits verification, understanding all the nuances of third-party insurances is tough enough for healthcare providers—let alone their patients. In WebPT’s most recent webinar— Suppressing Sticker Shock: How to Handle Your Patients’ High-Deductible Health Plans —co-hosts Heidi Jannenga, PT, DPT, ATC/L, the cofounder and president of WebPT, and WebPT CEO Nancy Ham provided a lot of great advice on how to have productive conversations about healthcare costs with your patients—without …

  • Common Questions from our Cloudy with a Chance of Reform Webinar Image

    articleFeb 13, 2017 | 13 min. read

    Common Questions from our Cloudy with a Chance of Reform Webinar

    In our first webinar of 2017 , WebPT’s co-founder and president, Heidi Jannenga, teamed up with CEO Nancy Ham to discuss the current and future healthcare trends that will impact PTs, OTs, and SLPs. (Missed it? No worries; you can view the complete recording here .) As always, we received quite a few questions during the presentation—way more than we could address live. So, we’ve put them all here, in one handy Q&A doc. Scroll through and …

  • Down with Denials! 5 Claim Fixes to Make Sure Your PT Clinic Gets Paid Image

    webinarApr 19, 2017

    Down with Denials! 5 Claim Fixes to Make Sure Your PT Clinic Gets Paid

    One denied claim might not sound off your billing alarm bells—but in reality, it should. That’s because—as with faulty plumbing—one leak often indicates a much larger issue. And all too often, rehab therapy practices fail to act quickly enough—and soon find themselves wading in a flood of lost revenue. But there are simple, proven, and affordable ways to not only plug your billing holes, but also reinforce your whole system so you’re less likely to bust a …

  • Cloudy with a Chance of Reform: 5 Key Healthcare Forecasts for 2017 Image

    webinarJan 5, 2017

    Cloudy with a Chance of Reform: 5 Key Healthcare Forecasts for 2017

    Predicting the weather is tough—just ask any meteorologist who has called for sun on the day of a major downpour. Well, predicting the fate of the US healthcare system isn’t much easier—there’s a lot up in the air, after all. But, even without a healthcare equivalent of Doppler Radar, there are a few key trends that are sure to have a major impact on PTs, OTs, and SLPs in 2017 and beyond. And to keep your practice …

  • 4 Keys to Keeping a Steady Cash Flow Image

    articleMay 18, 2016 | 5 min. read

    4 Keys to Keeping a Steady Cash Flow

    As a private practice clinic owner, you’re probably familiar with the cold sweat-inducing struggle to keep a steady cash flow. Claims management muck-ups, inefficient processes, staff issues, and lack of insight into your clinic’s financial health can leave you feeling like you’re riding a revenue rollercoaster. So, whether you’re trying to maximize reimbursements , combat employee theft , or optimize patient payments , these four keys to maintaining a steady cash flow will help you even out …

  • Odd Provider Out: Why PT Exclusion from MIPS is Bad for Future Payments Image

    articleMay 4, 2016 | 6 min. read

    Odd Provider Out: Why PT Exclusion from MIPS is Bad for Future Payments

    It’s official: rehab therapists are just a sashay away from exiting the PQRS dance floor. That’s because last week, the Centers for Medicare & Medicaid Services (CMS) issued a proposed final rule that, if adopted, will put into effect the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). And that, in turn, will give the green light to the Merit-based Incentive Payment System (MIPS) , a brand spankin’-new quality data reporting program that consolidates PQRS , …

  • 3 Common Rehab Therapy Credentialing Mistakes Image

    articleJul 18, 2018 | 6 min. read

    3 Common Rehab Therapy Credentialing Mistakes

    Proper credentialing is a crucial step in running a successful physical therapy clinic. If your clinic and therapists aren’t properly credentialed with insurance providers from the get-go, your bottom line might suffer. And it’s not just new clinics that are susceptible to making credentialing mistakes; in fact, any clinic that has gone through a change in ownership, rapid growth phase, or any other transition might find itself mired in credentialing headaches. But before we get to the …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.